Online form

Patient Registration / Pasiënt Registrasie


Patient Details / Pasiënt Besonderhede



Male / ManlikFemale / Vroulik

Medical Aid Details / Mediese Fonds Besonderhede


Details of Main Member - Person Responsible for Account / Besonderhede van Hooflid - Persoon Verantwoordelik vir Rekening


Next of Kin / Naasbestaande


Authorization

I agree that the address above is my chosen domicilium citandi et executandi for purposes of delivering and serving of all invoices, documents and legal processes. I further agree that that I am liable in my personal capacity to pay the amount owing. I further agree that in the event of my account being handed over to attorneys, that I will pay all attorney’s fees and costs on attorney and client scale together with further collection commission.

I Agree / Ek Stem