PERSON RESPONSIBLE FOR THE ACCOUNT

MEDICAL AID DETAILS (Please show medical aid cards)

FAMILY or FRIEND (not from same household)

FAMILY DETAILS

Dependents: Allergies: ID/ Date of Birth: Dep no:

Private patients are requested to settle accounts at the time of consultation.

All medical aid levies must be paid at the time of consultation.

All medical aid levies must be paid at the time of consultation.

Agreement

  1. I confirm that the above information is true and correct. I undertake to inform you of any changes thereto within 14 days of a change occurring.
  2. I undertake to forward all accounts to the medical aid society immediately and to settle all accounts that have not been paid by the medical aid society.
  3. I TAKE FULL RESPONSIBILITY FOR THE ACCOUNT.
  4. I take note of the fact that, in the event of non-payment by 90 days my name will be listed in “ITC” a national data base of slow payers.
  5. I accept that in the event of my non-compliance with the above undertaking I will be held liable for payment of all costs incurred in collecting such moneys from me as between attorney and client, including collection commission and tracing costs.
  6. I accept that fees higher than the National Reference Price List might be charged and I accept the fees charged by the practice.