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Personal Details Form

    Patient Details / Pasiënt Besonderhede

    Person Responsible for Account / Persoon Verantwoordelik vir Rekening

    Medical Aid / Mediese Fonds

    GAP Cover / Oorbruggingsfasiliteit


    Next of Kin / Naasbestande

    Family/friend not living with you / Familie/vriend wat nie by u won nie

    Referred By / Verwys Deur


    1. Our practice has no contract or agreement with your medical aid.

    2. We cannot negotiate with your medical aid on your behalf.

    3. Our rates are on a “fee for service” basis and are in accordance with what the South African Medical Association deems to be reasonable and appropriate.

    4. Consultation fees: Payable in full on the day of the appointment

    5. Cosmetic surgery: Quotations are negotiated individually and must be paid in full 2 weeks prior to surgery date.

    6. Elective procedures: Accounts must be settles in full within 14 days of receipt of invoice

    7. Emergencies: Accounts must be settled in full within 14 days of receipt of invoice.

    8. Interest will be added to accounts older than 30 days.

    9. Appointments not cancelled 24 hours in advance, are liable to be charged.

    10. I hereby consent to my details being divulged to the relevant 3rd parties eg, Medical Aid, Pathologist, Hospital or referring doctors etc.


    agree to the above mentioned terms