New Patient Information Feb 21 Written By Guest User Person responsible for account * First Name Last Name Title * Gender * Male Female Date of Birth * MM DD YYYY ID Number * Home address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email Employer * Occupation * Work Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Work contact number * (###) ### #### Work email address * Medical Aid provider * Medical aid option * Medical aid number * Benefits * Hospital Full Gap Cover If applicable Friend / Family * (Not at same physical address First Name Last Name Friend / Family contact number * (###) ### #### Friend / family home address * Address 1 Address 2 City State/Province Zip/Postal Code Country Relation * Patient Details * First Name Last Name Title * Relation to main member * Date of birth * MM DD YYYY ID Number * Contact Number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referring Doctor * Liability * I confirm that the information supplied is true. I agree that it is the responsibility of the member to obtain pre-authorisation for consultations and procedures. The member will carry all costs/penalties incurred as a result of failed pre-authorisations. I further understand that the member is personally responsible for settlement of the account and if applicable for submission thereof to the medical aid. Should legal steps be instituted for collection of this, I shall be liable for the costs on an attorney/client scale. I hereby give consent that the ICD 10 codes of my examination(s) may be disclosed to my medical aid and referring doctors. PLEASE NOTE: This practice charges Private rates. I agree I decline Thank you for your information. Our administrator will feedback to. you directly asap. Guest User
New Patient Information Feb 21 Written By Guest User Person responsible for account * First Name Last Name Title * Gender * Male Female Date of Birth * MM DD YYYY ID Number * Home address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email Employer * Occupation * Work Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Work contact number * (###) ### #### Work email address * Medical Aid provider * Medical aid option * Medical aid number * Benefits * Hospital Full Gap Cover If applicable Friend / Family * (Not at same physical address First Name Last Name Friend / Family contact number * (###) ### #### Friend / family home address * Address 1 Address 2 City State/Province Zip/Postal Code Country Relation * Patient Details * First Name Last Name Title * Relation to main member * Date of birth * MM DD YYYY ID Number * Contact Number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referring Doctor * Liability * I confirm that the information supplied is true. I agree that it is the responsibility of the member to obtain pre-authorisation for consultations and procedures. The member will carry all costs/penalties incurred as a result of failed pre-authorisations. I further understand that the member is personally responsible for settlement of the account and if applicable for submission thereof to the medical aid. Should legal steps be instituted for collection of this, I shall be liable for the costs on an attorney/client scale. I hereby give consent that the ICD 10 codes of my examination(s) may be disclosed to my medical aid and referring doctors. PLEASE NOTE: This practice charges Private rates. I agree I decline Thank you for your information. Our administrator will feedback to. you directly asap. Guest User
