Fill out the Patient registration form online
 
Phone 051 451 1106
to book an appointment
 
Or send an email
NEW PATIENT INFORMATION FORM - Afrikaanse vorm hier beskikbaar

 

 

Person responsible for the account (Fields marked with a * are required)

 

Title:
Surname:
Name:
Nick name:
Id. No: (13 numeric characters)
Date of birth: (dd-mm-yyyy)
E-Mail:
Street address:
Postal address:
Code:
Tel Home:
  Work:
  Cell:
Fax:
Occupation:
Employer:
Married / Unmarried / Divorced?

 

Medical Aid Information:

 

Medical aid:
Option:
No:

 

 

Information of spouse

 

Title:
Surname:
Name:
Nick name:
Id. No: (13 numeric characters)
Date of birth: (dd-mm-yyyy)
E-Mail:
Street address:
Postal address:
Code:
Tel. Home:
  Work:
  Cell:
Fax:
Occupation:
Employer:

 

 

Information of children

 

Name (as registered at the med. aid)

 Nickname Cell phone  ID / Date of birth 
1.
2.
3.
4.
5.

 

 

Relatives or friends in case of emergency

 

Relationship (e.g. Mother/Brother/Friend) Relationship (e.g. Mother/Brother/Friend)
Full Names: Full Names:
Address: Address:
Tel: Tel:

Who referred you to our practice?

PLEASE ADVISE US OF ANY CHANGE IN ABOVE INFORMATION

*I declare that the above information is correct and I take the responsibility for the payment of the
account for treatment rendered to me and my family.

*I  take responsibility for the full account and the immediate payment thereof if my Medical Aid does not cover the treatment as well as all administrative costs which could be charged for outstanding balances not paid within 60 days.

*I shall take the responsibility for any legal costs should my account be handed over for collection in the event of nonpayment.

By marking the adjacent box you agree to the above statement*:         Date: (dd-mm-yyyy)