Patient Details Form
Person Responsible For Account
*
Mr.
Mrs.
Ms.
Prefix
Full Names
Surname
ID
Address
*
Street Address
Suburb
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Patient Details
*
Mr.
Mrs.
Ms.
Prefix
Full Names
Surname
ID
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Method of payment
*
Please Select
Cash
Card
EFT
Medical Aid
Debit Order
Please take a clear photo of the patient's ID
*
Please take a clear photo of the front of your medical aid card
Please take a clear photo of the back of your medical aid card
Or upload your medical aid card
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I declare that the above information is true & correct. I am aware that even though a benefit check is done as a courtesy, I am liable for all shortfalls not paid by my medical aid. I will be responsible for additional costs incurred if my account needs to be handed over for collection. POPI Act: I give my permission for my information to be shared with my medical aid / referred to doctor.
*
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