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  • Particulars of patient

  • Person responsible for account

  • Two relatives that does not live at above address

  • Patients not on medical Aid must pay account on day of consultation.


    I understand that payment of services rendered remains my responsibility. The practice may claim on your behalf from your medical aid. However the practice do not Contract with your medical aid. Should your medical aid fail to settle part or all of the account you remain liable and responsible for settlement therof. You will pay the practice any co payment or any amount considerred as not “Coverred by your medical aid” .In the instance where a patient is devorced or a minor from such instance is brought to receive services. The party whom signs the contract will be held responsible for settlement of the account. Unless Written consent is given from the other party in such instance prior to services being rendered. The patient must acquaint themselves with their medical aid benifits as certain costs may not be coverred.

    I agree that should my account be handed over for collection, I shall be liable for all attorney and own client fees, collection charges and all disbursements. I agree that the account and payment of account is subject to the Prescribed Rate of Interest Act and that I remain liable for mora interest on accounts that have not been settled within 30 days.

    I agree to inspection of and negative listing of my credit information should my account remain outstanding. I agree to the jurisdiction of the Magistrate's Court despite the fact that the amount claimed might exceed the jurisdiction of the Magistrate's Court. I choose the above address as my domicilium. I undertake to notify the practice in writing within (7) seven days of any changes regarding the information giving above. No variation of or verbal agreements with any member of the practices staff shal be binding unless a written agreement signed by the practice manager will be binding. I agree that should I not cancel a consultation at least 24 hours in advance I remain liable for a full consultation fee.(cancelations must be via email or SMS only)

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