Patient Information

Patient Information | Terms and Conditions

Please fill out the fields below. Completion of this prior to your appointment speeds up the registration process immensely. Do not hesitate to contact our office on 010-500-5151 or info@cs.surgery should you have any questions.
Main Member Information / Person Responsible for Account
- This is the Main Member of the Medical Aid Plan or the Person who will be responsible to pay for the account.
- If the main member or main member's scheme declines to fund the care in full, or at all, the adult patient is legally liable for the full costs of the care received.
ID or Passport Number*
Title
Full Names*
Surname*
Gender*

MaleFemale
Date of Birth*

YearMonthDay
Date
Cellphone Number*
Home Phone Number
Work Phone Number
Email Address*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the Physical Address and Postal Address the same?

Yes
Postal Address

Postal Address Line 1

Postal Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer
Occupation*
Medical Scheme Information
Are you on a Medical Aid or Insurance?*

YesNo
Private Patient
Medical Scheme*
Medical Scheme Plan/Option*
Medical Scheme Membership Number*
Do you have Gap Cover?

YesNo
Patient Information
Is the Patient and the Main Member / Person Responsible For The Account the same person?

Yes
ID or Passport Number
Title
Full Names
Surname
Gender

MaleFemale
Date of Birth

YearMonthDay
Date
Cellphone Number
Home Phone Number
Work Phone Number
Email Address
example@example.com
Chronic Medical Conditions
Do you have Diabetes?*

YesNo
Do you have Asthma?*

YesNo
Do you have Epilepsy?*

YesNo
Do you have Hypertension?*

YesNo
Do you have any Allergies?*

YesNo
Specify the Allergies You Have
Do You Smoke?*

YesNo
For how many years have you smoked?
What type of product do you smoke?
E.g. Cigarette, Cigar, Vape etc.
Referral
Were you referred by another doctor/health professional to Dr Sofianos?*

YesNo
Who is the referring doctor/health professional?
Who is your usual or family doctor (GP)?*
How did you learn about Dr Sofianos?
Next of Kin
This is the person with whom we are authorised to speak to about your healthcare / outcome of your procedure.
Full Name*
Relationship to Patient
Email Address
example@example.com
Contact Number*
Practice Terms and Conditions
- Click here to view the Practice Terms and Conditions
Declaration
- I confirm that the information I have given is true and correct.
- I will notify the practice of any changes to my medical aid or contact details before proceeding with any further consultations or procedures.
- I confirm I have read the attached Practice Terms and Conditions and accept them in full.
Date

YearMonthDay
Date
Hour Minutes
Signature

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Patient Information | Terms and Conditions

Main Member Information / Person Responsible for Account

Medical Scheme Information

Chronic Medical Conditions

Referral

Next of Kin

Practice Terms and Conditions

Declaration