Online consultation application:

Thank you for contacting Dr Kiran Singh Urology in association with Invictus Mens Health.
This is an online consultation application request, designed to minimise your in-rooms waiting time, and improve your experience with the practices.
Should you not be comfortable with completing this online form, you can complete this at the time of your appointment in-rooms. A copy will be printed for your file, prior to your consultation with Dr Singh.

Making an appointment

Appointments can be made by calling the secretaries at either of the rooms (Ahmed Al Kadi Private Hospital (0314923481) or Netcare Umhlanga Medigate Medical Centre (0314930493).

No referral is necessary to make an appointment, but please remember that certain medical aids do not cover direct appointments with specialists, and may not reimburse you. Liaise directly with your medical aid in this regard.

Please remember to forward this document, to the practice once you receive an email attachment generated PDF.

This information will also reflect on your invoice to claim from your medical scheme/ GAP cover if applicable.

Special note: As of December 15, 2023, Dr. Kiran Singh has taken over Professor Zoltan Bereczky's patients (Sunningdale Medical Centre). Prof Bereczky's patients are required to complete this online consultation form to establish an electronic file, enabling continuous care and management. Additionally, please note that Prof Bereczky's patients will be seen at Medigate Medical Centre, located opposite Netcare Umhlanga Hospital.

IF YOU EXPERIENCE A PROBLEM COMPLETING THIS ELECTRONIC FORM, please CLICK THE WHATSAPP BUTTON BELOW FOR ASSISTANCE FROM THE PRACTICE.

IF NOT, PLEASE CONTINUE COMPLETING THIS FORM AND CLICK SUBMIT AT THE END OF THE DOCUMENT.

The practice is a member of the European Association of Urology and adheres to the guidelines set forth by the association.

For detailed patient information and educational material, please visit https://patients.uroweb.org

If you encounter any difficulty completing this document, please contact the practice.

You can reach us via email at drkiransinghurology@gmail.com or through our website www.urologydurban.co.za

Kindly schedule your appointment request with the following websites or phone the relevant rooms.*

General Urology http://www.urologydurban.co.zaMens Health Clinic https://invictusmenshealth.com

I am a potential client that wants to consult Dr Kiran Singh, Specialist Urologist as a:*

Outpatient basis - I want to see doctor in the consultation rooms at Ahmed Al-Kadi Hospital in MayvilleOutpatient basis - I want to see doctor in the consultation rooms at Medigate Medical Centre in UmhlangaIn-hospital referral from another doctor/ specialist/ CASUALTY/ emergency department at Ahmed Al Kadi Hospital or Netcare UmhlangaIn-hospital emergency in Emergency department/ casualtyAhmed Al-Kadi Hospital referralNetcare Umhlanga Hospital referralNetcare St Augustines Hospital referralLife Westville Hospital referral

What we as Specialist Urologists do:

Urologists diagnose and treat diseases of the urinary tract in both men and women. They also diagnose and treat anything involving the reproductive tract in men.

A Urologist is specialised in the diagnosis and surgical treatment of diseases and disorders such as Urinary Tract Infections (UTIs), Urinary Incontinence, Kidney Stones, Kidney Disease, Testicular Disorders, Enlarged Prostates, Male Infertility, Erectile Dysfunction as well as Uro-Oncology (e.g Prostate, Bladder and Kidney Cancer).

Outpatient (in-rooms) consulting days:

Monday to Saturday 09h00 to 17h00

We have admission and theatre operating rights at:

Ahmed Al-Kadi Private Hospital
Netcare Umhlanga Hospital
Life Westville Hospital
Netcare St Augustines Hospital
Busamed Gateway Private Hospital

Kindly phone or WhatsApp the relevant practice, with regard to further details.

If you are unable to attend the appointment kindly cancel within 24 hours. No-shows will be billed, as we book patients STRICTLY on an appointment-basis.

At time of consultation - PLEASE SUPPLY RECEPTION WITH:

Identity cardMedical aid card

Preferred consultation date considering the above:

Date

Reason for referral to a Specialist Urologist:*

Self-referral - I want to see a urologist as I believe I have a urological problemMy admitting physican/ doctor referred me to see a urologistI’m not sure

Preferred practice location and contact person:*

Ahmed Al-Kadi Private Hospital (Mayville) - Suite 4, Waterfall Suites, Basement Level of the main hospital - 490 Jan Smuts Hwy, Mayville, Durban, 4058 —— Contact person: Yedeshnee Govender or Rivi Singh - Landline 0314923481 or WhatsApp 0659786966 or email drkiransinghurology@gmail.comMedigate Medical Centre (Umhlanga) Suite 16a, opposite the parking lot of Netcare Umhlanga Hospital on Medigate Road, Umhlanga Ridge, Durban, 4321 ——Contact person: Roselyn Govender - Landline 0314930493 or WhatsApp 0719108915 or email drkiransinghurology@gmail.com

Relevant investigation request prior to consultation or please email drkiransinghurology@gmail.com ANY INVESTIGATIONS ALREADY PERFORMED

Blood test request (Lancet Laboratory to Ampath Laboratory)Radiology requestQuote for surgical procedure

Name*

First NameLast Name

Identity Number (ID) or Passport Number to create your electronic file (Please use your ID number as your reference file *

Date of Birth

Date

Residential or postal address

Contact number (preferably cell/ WhatsApp) *

Please enter a valid phone number.

Alternate contact number

Please enter a valid phone number.

Email*

example@example.com

Employer

Occupation

Medical aid/ scheme

Medical aid/ scheme number

Medical Aid Option

Dependent code of patient

How does payment work?

We aim to be open and honest about all aspects of the consultation including diagnosis, treatment and the cost thereof so please do not hesitate to ask should you require any additional information.

Each medical aid has their own ‘scheme rate’ based on the previously used NHRPL or National Health Reference Price List. In July 2010, Acting Judge Ebersohn of the North Gauteng High Court judged the RPL to be ‘unreasonably low’ with health care practitioners not able to cover their costs at this rate and it was therefore set aside.

Practitioners are thus allowed to set there own rates, within reason.

As such, there will almost always be a difference between the costs involved and what your medical aid is prepared to cover, especially when it comes to surgery.

The account remains your personal responsibility and must be settled with the practice as detailed below after which you may approach your medical aid for reimbursement.

The practice accounts are managed by Duvesco Billing Agency.

Consultation fees are payable on the day of appointment and rates are available from the receptionists. We accept cash and major credit/debit cards. A payment receipt will be provided so that you may claim the medical aid rate portion of the consultation. Emergency or after hours consultations will be subject to an additional fee.

NOTE: The consultation fee is only for the appointment itself ie history, basic examination & diagnosis. Any procedures required to make the diagnosis, including but not limited to, ultrasound, uroflowmetry, flexible cystoscopy, wound care etc, are chargeable separately (see below). These will be charged to the medical aid if applicable.

In the event the medical aid rejects the claim for whatever reason, the patient is liable for these charges.

Surgery

An estimate of the total cost will be provided before scheduling surgery. Fees for other health professionals, such as anaesthetists and physicians, as well as hospital fees, are charged separately by the relevant entities.

Remuneration Guideline

All medical aids are accepted.
The practice aims to provide a quality, and not a quantity driven service.
This is just a guideline. All accounts will be generated on an individual basis, considering time and skill required.
Please email the practice for Terms and Conditions including the current billing policy.

GAP cover*

YesNo

Gap cover policy and member number: *

GAP cover*

I hereby provide consent to the medical practice, granting them the authority, through their designated billing agent, to engage in negotiations for the settlement of any outstanding medical invoices (specifically theatre procedures) with your respective GAP cover for direct payment.

Consent*

Dr Kiran Singh is a Private Specialist Urologist who charges private rates. The below information is to advise you the patient and/ or member of the practice’s charges:R1500.00 is due at the time of your CONSULTATION, which includes basic ultrasound if necessary. THIS FEE EXCLUDES OTHER INVESTIGATIONS (blood work, uroflowmetry studies). Investigations performed during consultations (Uroflowmetry) are billed and sent to your medical aid or settled by CARD/EFT payment at time of initial consult. Weekend consultations will be charged at R2000, including basic ultrasound if necessary.TREATMENT (medication and surgical procedures) are billed and sent to your medical aid or settled by CARD/EFT payment at time of initial consult.All theatre procedures are billed at a rate of 300%, if you are on GAP cover then please submit the account provided after your medical aid has paid if you do not have Gap cover then rates may be discussed with Dr Singh.For more information, please refer to our website.

Acknowledge of billing structure of the practice*

I (Name and Surname submitted above) have read the above provided information and understand what I am signing for.I agree that I have been duly notified of the practice rates and should my medical aid fail to make full payment I will thereafter settle the remaining balance.Should I not be able to afford the balance I will immediately notify the rooms and / or accounts of DUVESCO BILLING in order to make arrangements or advise of my current financial situation.I accept that a payment arrangement may not always be applicable or may not be advisable given any or all circumstances of my account.

Terms and conditions of payment*

TERMS AND CONDITIONS OF PAYMENT:ALL INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT AND ANY COST INCURRED IN RELIANCE THEREOF SHALL BE SOLELY MY RESPONSIBILITY.IN THE EVENT OF MY MEDICAL AID NOT PAYING, I ACCEPT THAT I WILL BE RESPONSIBLE FOR PAYMENT OF THE FULL SUM OF THE OUTSTANDING AMOUNT DATED ON THE RECEIPT OF MY INVOICE.I ACCEPT THAT IT IS MY RESPONSIBILITY TO OBTAIN AUTHORIZATION FROM MY MEDICAL AID PRIOR TO CONSULT AND TO FOLLOW UP WITH MEDICAL AID AND GAP COVER.I ACCEPT THAT PAYMENT IS PAYABLE WITHIN 30 DAYS OF INVOICE. IN THE EVENT OF BOTH MEDICAL AID AND MYSELF, FAILING TO PAY THE AMOUNT OUTSTANDING, THE MATTER WILL BE HANDED OVER FOR LEGAL PROCEEDINGS.I ACCEPT THAT I WILL BE RESPONSIBLE FOR ALL LEGAL COSTS INCURRED ON AN ATTORNEY AND CLIENT SCALE, TOGETHER WITH COLLECTION, COMMISSION, VAT AND TRACING FEES.

Signature*

Date