ONLINE REGISTRATION FORM

MAIN MEMBER INFORMATION / PERSON RESPONSIBLE FOR THE ACCOUNT

MEDICAL AID DETAILS (PLEASE SHOW MEDICAL AID CARD)

FAMILY OR FRIEND (NOT FROM SAME HOUSEHOLD)

PATIENT INFORMATION:

FAMILY DETAILS:

Add Additional Family Member

Private Patients are requested to settle accounts at the time of consultation.

Agreement

By signing this form

1. I confirm that the above information is true and correct,

2. I confirm that even if I am a member of a medical fund, I remain responsible for payment of my account and any amount not paid by the medical aid;

3. I accept that in the event of non-compliance with the above, I will be held liable for all costs incurred in collecting any outstanding moneys, as well as interest that will be charged on arrear accounts (after 90 days).

NB:

lF YOU DO NOT KEEP YOUR APPOINTMENT (FOR ANY REASON WHATSOEVER, APART FROM EMERGENCIES) AND YOU HAVE NOT LET US KNOW AT LEAST 24 HOURS BEFORE THE APPOINTMENT, WE RESERVE THE RIGHT TO CHARGE A FULL CONSULTATION FEE AS WE HAVE KEPT THE SLOT OPEN FOR YOU AND COULD NOT FILL IT WITH ANOTHER PATIENT