This is the Patient Information Form
ID Number:
Surname:
Full Name:
Title:
MrMrsMiss
Date of Birth:
Home Language:
Address:
Postal Address:
Tel(Home):
Tel(Work):
Cell:
Email:
Relative / Friend Name:
Relative / Friend Tel Number:
General Practitioner:
Referring Dr:
Occupation:
Employer:
Medical Aid Name:
Medical Aid Number
Medical Aid Plan:
GAP Cover YesNo
Dependent Number:
Gender: MaleFemale
I, the undersigned, do hereby acknowledge that I have been informed that this practice does not charge the rates that the Department of Health has unilaterally determined for doctors and which are known as the reference price list (RPL).
Confirm that I am aware that the RPL values for services are available from the Dept of Health (Tel. No 012 312 0000) Accept that I am fully responsible for payment for services rendered and should I not pay timeously, understand that I will be liable for debt recovery costs on an attorney and own client scale.
Signature
This is not an actual appointment form. The below form is to request an appointment. We will get back to you to confirm a date and time.
Your name
Your email
Your contact number
Date of Birth
Your message
