Pattient Particu
ulars: Surname Datee of Birth I.D N
Number Name
Dr/Mr/Mrs/M
Miss/Master
Occupation
Hom
me Language Referred by Cell Workk Hom
me address GP/Specialistt
Home
E‐mail
Postal addresss
Maiin member of Medical aid / Perso
on responsib
ble for acco
ount Name of fund Number
Main
n member Nam
me Surname
ID Nu
umber E‐maail address m any of the fo
ollowing? If so
o, encircle pleaase: Diabetes, cancer, asthm
ma, blood presssure, osteopo
orosis, rheumatoid Do you suffer from
arthrritis or any oth
her health con
ndition. __________________________________________ Med
dical Aid Pattients: Your a
account will b
be submitted
d to the Mediccal aid electrronically, but you as the patient
p
will be
e liable
for a
any outstandiing amount th
hat has not been
b
paid in 3
30 days. Ourr contract is w
with you the patient and NOT
N
the med
dical
aid.
NT THAT MY
Y ICD10 COD
DES MAY BE
E GIVEN TO
O MEDICAL A
AID.
I GIIVE CONSEN
Priva
ate patients: Must
M
please settle amount a
after treatmentt, or arrangement to be mad
de with the practice owner. Iff account is no
ot
settle
ed by within 10
0days of last trreatment date the settlemen
nt discounted w
will be forfeited
d.
All P
Patients
All ap
ppointments n
not cancelled 2 hours in adva
ance, will be ccharged at full price. Your tre
eatment fee do
oes not include
e consumables and
exerccise programss.
In the event of Div
vorce the parrent accompa
anying the minor and signing the patien
nt form is the person responsible for
s account. In tthe event of a
any legal actio
on being insttituted agains
st me for reco
overy of any a
amount whats
soever,
settlement of this
all be liable fo
or all legal cos
sts incurred i.e.
i 20% admiin fee, 10% re
eceipting fee, interest at th
he rate of 9.00
0% from date of
I sha
services rendered
d until date off payment in full and all le
egal costs inc
curred in the rrecovery of th
he outstandin
ng amount. Sh
hould I
defend the matterr I will be held
d responsible
e for costs on
n an attorney//client scale. T
The National Credit Act 34
4 of 2005 is no
ot
h been han
nded over. I understand that all dealings will be done
e with
applicable to this claim. Once my account has
Absolute Debt S
Solutions an
nd not our o
office.
SIGN
NATURE: ___
____________
____________
_____
DATE: _____
____________
__________
I herreby give consent to physiiotherapy trea
atment being performed b
by a registered
d physiothera
apist.
My trreatment may
y include phy
ysical activity
y. All exercise
e testing and physical
p
activ
vity sessions will be superrvised and
monitored by a qu
ualified physiotherapist. M
My treatment may include dry needling therapy done
e by a qualifie
ed physiotherrapist.
I und
derstand that there are inh
herent risks associated witth physical ac
ctivity and recognize that it is my respo
onsibility to provide
p
accu
urate and com
mplete medica
al/ health and
d performanc
ce history durring any activ
vity. I also giv
ve informed co
onsent for da
ata to
be used in any an
nonymous ma
anner for purpose of scien
ntific or medic
cal research.
NATURE: ___
____________
____________
_____
SIGN
DATE______
____________
___________