PATIENT INFORMATION

Title
*Surname
*Full Name
*Identification Number
Gender
*Age
Email
Language
*Mobile Number
Work Number
*Dep code
Referring Dr & Tel No.

MEDICAL AID DETAILS


Medical Aid Name
Medical Aid Option
Medical Aid No
M/M Dep code

PERSON RESPONSIBLE FOR PAYMENT


Title
*Surname
*Full Name
*Identification Number
Relationship to patient
Email
Gender
Language
Mobile Number
Work Number
Home Number
Postal Address
Residential Address
Employer
Profession
Work Address

NEXT OF KIN DETAILS


*Name & Surname
*Relationship to patient
*Contact No.

I hereby certify the above is true and correct. All consultation fees are payable on the day of the consultation. Dr Naidoo enters into an agreement with you and not your medical aid. It is the members’ responsibility to inform the accounts department of any changes in personal details. I understand that should my medical aid not pay claims, it will be my responsibility to pay Dr Naidoo and claim back from the medical aid. Outstanding accounts must be settled strictly within 14 days. All overdue accounts exceeding 14 days will be listed on ITC and handed over to the attorney. A charge will be added on all overdue accounts. Should your account be handed over for collection, you will be liable for all legal costs on attorney and client scale, collection charges and tracing fees, as well as VAT where applicable. I hereby choose the given address as my domicilium citandi et executandi address. Please note private fees are billed.

To download a document about patient fees, please click here


SIGNATURE (Below)
(Person responsible for payment)