Booking Form

To speed up the booking process, please complete the form below and submit it to us.

Please note that this practice does not send accounts directly to any Medical Aid. You are thus personally responsible to claim accounts from your Medical Aid/Hospital Plan.

By Submitting this form you undertake full responsibility for all attorney and client, collection commission, tracing fees and interest on overdue accounts.

Click Here to download a printable version of this form. Please complete the form and either fax it back to us on 051 448 3020 or bring it in to the office.

Patient Details

Patient Details
*Surname: *Title: *Initials:
*Date of Birth: *ID Number:
*Occupation: *Home Language: *Marital Status:
*Contact No: *E-mail:

Person Responsible for Account

Person Responsible for Account
*Full Name: *Title:
*Home Address: *Occupation:
*Contact No:
*Postal Address: *Tel (Work):
*Tel (Cell):
*ID No: *E-mail:

Medical Aid

Medical Aid
*M.A. Name: *Number:
*Plan: *Memeber's Name:

Medical Insurane Policy / Hospital Plan

Medical Insurance / Hospital Plan
*Number:    

Nearest Family/Friend (Not at the same address)

Nearest Family/Friend
*Name: *Relation:
*Address: *Tel:
*Cell:

Referred By

Referred By
*Name: *Address:

Your Usual GP

Your Usual GP
*Name: *Address:

Please review the form and then click Submit