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Menu
HOME
ABOUT
CONSULTATIONS
CONTACT
DEUTSCH
CLIENT INTAKE FORM
CLIENT INTAKE FORM
CLIENT INTAKE FORM
CLIENT
Surname
Name
Gender
Date of Birth
Referred by
Email
PERSON RESPONSIBLE FOR THE ACCOUNT (if different from above)
Surname
Name
ID/Passport Number
Home Address
Postal Address (If different from Home Address)
Email
Contact
Alternative Number
MEDICAL INSURANCE DETAILS
Name of Insurance
Principal Member
Membership Number
PLEASE NOTE
The above information is required for identification and billing purposes.
Appointments are 45 minutes in duration.
Appointments not altered 48 hours in advance, will be charged for.
In light of the Protection of Personal Information Act (POPIA), all medical aid members are personally responsible for submitting any claims themselves (and within the medical aid's required time frames).
Any claims to a medical-aid scheme will require an associated ICD-10 code.
Statements of account , and any other special communications as requested by you, are sent via email. For more information, please view our Privacy Policy.
Please get in touch with us if you have any queries or concerns relating to data privacy.
By signing, you are acknowledging that you understand and agree to the above terms, as well as to our privacy policy.
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By clicking AGREE, you are acknowledging that you understand and agree to the above terms, as well as to our privacy policy.
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