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Patient Form Pg1

PATIENT INFORMATION FORM AND FINANCIAL AGREEMENT CONTRACT

Kindly complete this form, which will become our office record and your financial agreement contract and will assist us in compiling a correct treatment plan.

ALL INFORMATION WILL BE KEPT IN THE STRICTEST OF CONFIDENCE

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:

  1. The practice is contracted out of medical aid and therefore does not limit itself to NHRPL fees.
  2. A description of the practice fee structure and a cost estimation will be prepared at any time on request
  3. This practice is not a registered credit provider and may not extend credit.
  4. Fees are strictly payable after every visit.
  5. Appointment must be cancelled at least 6 HOURS before the time, otherwise a fee of R300 per half hour will be charged
  6. Should you have a genuine financial problem, please feel free to discuss this with me.
  7. Please inform me immediately of any changes in your address or patient details.
  8. All accounts over 30 days will be charged 5% interest.