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Particulars of Patient

Your Details

Date of Birth

A relative that does not live at the above address

Relative Name and Surname

Medical aid and Main Member details

We are a private practice and do not accept medical aids: medical aid information supplied will reflect on your account for claiming purposes. You claim directly from your medical aid using the statement that we will provide on the day of the treatment.

Prefered option
Your Full Names and Surname
Your preferred choice to be contacted?
How did you get to know about us?

Medical History

Does one of the following apply to your medical background?

0 - 500 Characters
0 - 500 Characters
0 - 500 Characters
0 - 500 Characters
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Agreement by Patient

I agree and understand that the contract is entered into by me and the practice and NOT the medical aid.

I understand that the payment of services rendered remains my responsibility and as this is a PRIVATE PRACTICE payment will be made immediately.

I agree and undertake to cancel all appointments not less than 24(twenty-four) hours before such, should I fail to cancel, I will remain liable for R500 per half hour of late cancellation.

Appointments longer than one hour will require cancellation 48 (forty-eight) hours before the scheduled appointment.

All accounts are charged at private practice fees and remain my liability.

I agree that should my account be handed over for collection, I should be liable for all attorney and own client fees, collection charges, and all disbursements.

I agree that the account and payment of the account is subject to the Prescribed Rate of Interest Act and that I remain for more interest on accounts that have not been settled within 60 days.

I agree to the inspection of and negative listing of my credit information should my account remain outstanding.

I choose the above address as my domicilium.

Declaration 2
Confirmation of Date and Time Serves as Acknowledgment of Signature.