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 .