MB.ChB (Stell) FC Plast Surg (SA)
Practice no: 0230197
Phone us: +27 (0) 21 851 3400
Email us:
info@doctortoogood.co.za
HOME
THE TEAM
PROCEDURES
PROCEDURES
BEFORE & AFTER
OUR OFFERING
Somerset Surgery Day Hospital
Guest house and Recovery Retreat
Skin Clinic
Traveling for Surgery
Customise your Recovery
CONTACT
MEDIA
HOME
THE TEAM
PROCEDURES
PROCEDURES
BEFORE & AFTER
OUR OFFERING
Somerset Surgery Day Hospital
Guest house and Recovery Retreat
Skin Clinic
Traveling for Surgery
Customise your Recovery
CONTACT
MEDIA
584
page-template,page-template-full_width,page-template-full_width-php,page,page-id-584,strata-core-1.1.1,strata-child-theme-ver-1.0.0,strata-theme-ver-3.4,ajax_fade,page_not_loaded,smooth_scroll,wpb-js-composer js-comp-ver-8.0.1,vc_responsive
Personal Details Form
"
*
" indicates required fields
Step
1
of
6
16%
Account Number / Rekening Nommer
*
PATIENT DETAILS / PASIËNT BESONDERHEDE
Name
*
Title / Titel
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Last
Date of Birth / Geboortedatum
*
DD slash MM slash YYYY
I.D. Number / I.D. Nommer
*
Occupation / Beroep
*
Language / Huistaal
*
Marital Status / Huwelikstatus
*
Tel (H)
Tel (W)
Cel / Sel
*
E-mail / E-pos
*
Fax / Faks
PERSON RESPONSIBLE FOR ACCOUNT / PERSOON VERANTWOORDELIK VIR REKENING
Name
*
Title / Titel
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Last
I.D. Number / I.D. Nommer
*
Home Address / Woonadres
Code / Kode
Postal Address / Posadres
Code / Kode
Work Address / Werkadres
Code / Kode
Tel (H)
Tel (W)
Cel / Sel
*
E-mail / E-pos
*
Fax / Faks
MEDICAL AID / MEDIESE FONDS
Name / Naam
*
Option / Opsie
*
Number / Nommer
*
Members Name / Hooflid se naam
*
GAP Cover / Oorbruggingsfasiliteit
*
Yes / Ja
No / Nee
Tel (H)
Tel (W)
Cel / Sel
*
NEXT OF KIN / NAASBESTANDE
Name / Naam
*
Relationship / Verwantskap
*
Address / Adres
Code / Kode
Tel (H)
Tel (W)
Cel / Sel
*
FAMILY/FRIEND NOT LIVING WITH YOU / FAMILIE/VRIEND WAT NIE BY U WOON NIE
Name / Naam
*
Relationship / Verwantskap
*
Address / Adres
Code / Kode
Contact Phone Number / Kontak Foon Nommer
*
REFERRED BY / VERWYS DEUR
Name / Naam
Tel
PRACTICE TERMS: PLEASE NOTE:
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.
Consent
*
I agree to the above mentioned terms
*
Date
*
DD slash MM slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
Δ