PRIVATE MEDICAL PRACTICE

PRIVATE MEDICAL PRACTICE

(TELEHEALTH DIVISION) New patient intake Form
Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Valid Email Address
example@example.com
List Chronic conditions and allergies if any.
List out all current medication.
List your main compliant / symtoms or request ( eg, will need repeat precription/ medical report/ certificate / PDP ect.)*
Are you on Medical Aid or Healthinsurance

YESNO
IF YES , take a picture or upload medical aid card.
Cancelof
Payment Details
Consultation Fee is only R250 cash or Eft. This includes medical consultation with prescriptions, refferal letter, medical certificates or any required medical documentation .

Payment Methods:
• Selected Medical Aids / Health 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
CONSENT & DECLARATION FOR MEDICAL TREATMENT AND
INFORMATION PROCESSING

I, the undersigned, hereby voluntarily consent to medical consultation, examination, and/or treatment by Dr. HP Edwards or delegated healthcare professionals. This includes any necessary prescriptions, referrals, 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 I acknowledge that this consent is provided freely and may be withdrawn in writing.
TERMS AND CONDITIONS*

I ACCEPT
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