Constantiaberg Oncology Unit Appointment Form

Patient Information

Title:

Initials:

Date of Birth:

Surname:

First Names:

I.D. Number:

Employment Details

Occupation:

Tel Number:

Employers Name:

Work Tel Number:

Contact Details

Email:

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If the Postal Address is the same as above

Yes

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Tel No:

Local Tel No:

Next of kin not residing on the above address

First and Last Name:

Tel No:

Relationship

Particulars of person responsible for payment

Medical Aid Name:

Option(Compulsory):

Membership Number:

Dependant Code:

Last Name:

Title & First Name:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I.D. Number of main member:

Referring Doctor Details

Referring Doctor:

Practice No:

General Practioner:

Practice No:

Other Doctors to inform:

Please contact your medical aid to ascertain the extent of cover for the treatment to be undertaken and whether you need to register for specific benefits or obtain an authorization number. This is important as you will ultimately remain responsible for the payment of all accounts. All consultation fees are being charged according to the recommended tariff of our professional organization. These fees are to be settled directly with us. All treatment fees are charged according to Scale of Benefits as determined by the Medical Aids. Please feel free to discuss any queries in this regard with one of us. Interest will be charged on all overdue accounts. In the event of non-payment, you will be held liable for any legal costs incurred on an attorney client basis.

I declare that I am aware of the contents of the above and accept the terms as outlined.