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Patient Information Form

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Medical Health Information

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PATIENT INFORMATION










PERSON RESPONSIBLE FOR THE ACCOUNT













MEDICAL AID DETAILS








MEDICAL HEALTH INFORMATION

1. MEDICAL/SURGICAL HISTORY:

Do you have now or have you ever had?



2. CURRENT HEALTH:



3. MEDICATION:


4. DERMATOLOGIC HISTORY:

Do you have now or have you ever had?


5. ALLERGIES:



6. FAMILY HISTORY:

Do you have a family History of:



7. FEMALES:





CONSENT TO THE FEES BEING CHARGED BY THIS PRACTICE:

I, the undersigned, do hereby

  • Acknowledge that I have been informed that this practice does not charge the rates that the Department of Health has unilaterally determined for doctors and which are known as the Reference Price List (RPL);
  • Confirm that I am aware that at this practice, fees are charged at up to 3 times the RPL;
  • Accept that I am fully responsible for payment on the same day as services rendered and should I not pay timeously, understand that I will be liable for Dept recovery costs on an attorney and own client scale.
  • Interest will be charged on overdue accounts after 30 days
  • Accept that all special investigations are not included in the consultation and will be charged extra.