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CLIENT INTAKE FORM

CLIENT INTAKE FORM

CLIENT INTAKE FORM

CLIENT
PERSON RESPONSIBLE FOR THE ACCOUNT (if different from above)
MEDICAL AID DETAILS
PLEASE NOTE
  • The above information is required for identification and billing purposes.
  • Appointments are 50 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 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 contact 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.