Patient Administration

English Administration Documents

Afrikaans Administration Documents

Patient Information

Surname *

Full name *

Phone number

Date of birth *

Person Responsible for account

Surname *

Full name *

Date of birth *

Physical Address *

Postal Address *

Employer

Phone *

Medical Aid

Do you have a Medical Aid *

Medical Plan/Option:

Member Dependent Nr:

Do you have a Medical Aid *

MA Nr:

Client Dependent Nr:

Family Doctor

Name

Phone

Please note: A flat rate of R3200.00 for the first interview is to be paid in cash. Thereafter medical aid rates, or alternatively cash rates, are charged. Please bring a copy of your medical aid card and ID. All accounts are payable upon receipt thereof and interest will be charged on payments later than 30 days. Reports and interviews are confidential and will only be discussed with other professionals when it is in the interest of the client. This practice uses electronic media and, although all reasonable steps are taken to ensure confidentiality, hacking may take place.

If you wish to cancel an appointment, please ensure that it is done at least 24 hours before the time, as you will be held responsible for the cost of the session, should you fail to do so.

Name & Surname

accept responsibility for the full payment of the account. *

Yes

Date of form submission *

Signature

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