Private Medical Practice (Telehealth Division)
Patient Intake Form
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Female
Male
Email
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal code
Emergency Contact Information
MEDICAL INFORMATION
List your main complaint/symptoms or request ( eg, Sick note, prescription required )
*
List any chronic health problems you may have
List out all current medication
List out allergies
What problems are you seeking help for?
Payment Details
Fee is only R250. This includes medical consultation with prescriptions, medical certificates (sick note) 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
Are you on Medical Aid or Health insurance
Yes
No (skip section if NO and write down CASH PAYMENT DETAILS if EFT will be used )
(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, 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for administrative or occupational health purposes).I acknowledge that this consent is provided freely and may be withdrawn in writing at any time.
Signature
Don't forget to book after submitting the form. Click blue booking button the website to book.
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