CLIENT INTAKE FORM

CLIENT

Surname

Name

Gender

Date of Birth

Referred by

PERSON RESPONSIBLE FOR THE ACCOUNT (if different from above)

Surname

Name

ID/Passport Number

Home Address

Postal Address (If different from Home Address)

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.

DATE

By clicking AGREE, you are acknowledging that you understand and agree to the above terms, as well as to our privacy policy. *

AGREE