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Patient Information:
ID Number:
Surname:
First Name:
Initials:
Title:
Home Language:
Cell Number:
Use cell number for appointments / test results?
Yes
No (Main members cell number will be used)
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:
Female
Male
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?:
Yes
No
Medical Aid Details:
Medical Scheme:
Option / Plan:
Member No:
Gap Cover:
Yes
No
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?
Yes
No
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
.
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