Private Medical Practice (Telehealth Division)

Private Medical Practice (Telehealth Division)

Patient Intake Form
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Gender
Email
example@example.com
Phone Number
Format: 0000000000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal code
Emergency Contact Information
Medical Information

Add brief medical history or Requests
List your main complaint symptoms and documentation required during consultation ( eg Prescription, Represcription, Medical Report, Medical,Certificate,Specialist Hospital Refferal as indicated , Z88, PDP ect)
List any chronic health problems you may have
List out all current medication
List out allergies
What problems are you seeking help for?
Are you on Medical Aid or Health insurance
(IF No Skip Section) IF YES : Medical Aid / Health Insurance Provider
Take Picture of Medical Aid Card. (Front)
Medical Aid Card (back)
CONSENT & DECLARATION FOR MEDICAL TREATMENT AND INFORMATION PROCESSING

I, the undersigned, hereby voluntarily consent to medical consultation, examination, and/or treatment by Dr. Heinri Edwards or delegated healthcare professionals. This includes any necessary prescriptions, referrals, laboratory investigations, and the issuing of medical documentation.I understand and agree that my personal and medical information will be collected, stored, and processed for the purposes of healthcare service delivery, in accordance with the Protection of Personal Information Act (POPIA).I further consent to the sharing of my relevant information with: medical specialists or referring healthcare providers, Hospitals or healthcare facilities, Medical schemes, my employer (where necessary for administrative or occupational health purposes). I acknowledge that this consent is provided freely and may be withdrawn in writing at any time.
Acknowledgement of Financial Responsibility

I hereby acknowledge and understand that I am personally responsible for the payment of all consultation fees and any associated costs incurred during my care. I agree to settle all accounts in full privately where medical schemes or insurance do not apply or where claims are rejected or not paid in full. I understand that failure to do so may result in further administrative or legal action in accordance with practice policy.
Signature
Click SUBMIT below. ⬇️
EFT / CASH Payment Details

Consultation Fee is only R250. Payment required after consultation unless otherwise specific by accounting department. The consultation fees includes medical consultation with prescriptions, medical certificates (sick note) or any required medical documentation. Payment Methods: • Selected Medical Aids / Health Insurances • Instant / Immediate/ payshap payment EFT Only. Banking Details: NEDBANK , Acc number-1288988117 ,Branch Code: 198765, Reference: Patient Full Name, Acc Name : Dr Heinri Edwards
Don't forget to BOOK after submitting the form. Click any Booking button on the website to book.
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Private Medical Practice (Telehealth Division)

Medical Information

CONSENT & DECLARATION FOR MEDICAL TREATMENT AND INFORMATION PROCESSING

Acknowledgement of Financial Responsibility

EFT / CASH Payment Details