Patient Form 1 PATIENT INFORMATION Surname: First Names: Date of Birth: Home Address: Work Address: Occupation: Postal address: Tel (W) : Tel (H): Cell: I.D Number: Email: FINANCIALLY RESPONSIBLE PARTY INFORMATION (If not the same as above) Surname: First Names: Date of Birth: Home Address: Work Address: Occupation: Postal address: Tel (W) : Tel (H): Cell: I.D Number: Email: MEDICAL AID (In order for you to claim back from your medical aid) Name: Medical Aid number: Main Member: DEPENDANTS Dependant 1 Name: Date of Birth: Remarks: Dependant 2 Name: Date of Birth: Remarks: Dependant 3 Name: Date of Birth: Remarks: NEAREST FAMILY MEMBER / FRIEND Name: Relationship: Tel (H) Tel (W): Cell: PLEASE NOTE THE FOLLOWING: The practice is contracted out of medical aid and therefore does not limit itself to NHRPL fees. A description of the practice fee structure and a cost estimation will be prepared at any time on request This practice is not a registered credit provider and may not extend credit. Fees are strictly payable after every visit. Appointment must be cancelled at least 6 HOURS before the time, otherwise a fee of R300 per half hour will be charged Should you have a genuine financial problem, please feel free to discuss this with me. Please inform me immediately of any changes in your address or patient details. All accounts over 30 days will be charged 5% interest. I, HEREBY STATE THAT I FULLY UNDERSTAND ALL THE ABOVE MENTIONDED FACTS AND AM AWARE THAT THIS IS A LEGAL AND BINDING CONTRACT OF ARRANGEMENT BETWEEN DR JJ SERFONTEIN AND MYSELF.