Patient Information:

    ID Number:
    Surname:
    First Name:
    Initials:
    Title:
    Home Language:
    Cell Number:
    Use cell number for appointments / test results?
    Home Number:
    Work Number:
    E-mail Address:
    Occupation:
    Date of birth:
    Marital Status:
    Patient Height (meters):
    Patient Weight (kgs):
    Patient Age (years):

    Person Responsible for Account:

    ID Number:
    Date of birth:
    Home Language:
    Gender:
    Surname:
    First Name:
    Initials:
    Title:
    Cell Number:
    Home Number:
    Work Number:
    E-mail Address:
    Postal Address:
    Postal Code:
    Physical Address:
    Postal Code:
    E-mail Statements?:

    Medical Aid Details:

    Medical Scheme:
    Option / Plan:
    Member No:
    Gap Cover:
    M/M Department Code:

    Next Of Kin:

    (Not from the same physical address)

    Surname:
    First Name:
    Initials:
    Title:
    Cell Number:
    Relationship to Patient:

    Other Information:

    Were you referred by a doctor? YesNo
    Referring Doctor's Name:
    Tel Number:
    Fax Number:
    How did you hear about us?
    I am aware that this practice does not charge the rates that the Department of Health has determined for medical pratitioners and which is known as the Reference Price List (RPL). I am also aware that this practice may charge up to a rate of three times the RPL. I acknowledge that I am fully responsible for the payment of services rendered by the doctor should the medical fund not pay in full.

    I have read and accepted the Terms & Conditions .