New Patient Form

Patient Details

Surgeon

Title

First Name

Last Name

ID Number

Phone Number

Allergies

Marital Status

Spouse's First Name

Spouse's ID Number

Spouse's Last Name

Spouse's Phone Number

Medical Aid

Medical Aid Number

Main Member's Name

GAP Cover

Plan Option

Dependent Number

Main Member's ID Number

Name of Referring Doctor

Name of GP

Address of GP

First Name

Address

Last Name

Phone Number

All patients are requested to settle accounts at the time of consultation.
Notwithstanding any membership of a medical aid scheme, you are personally liable for payment of all accounts rendered to the patient.
I agree to pay Prof Darlene Lubbe/Dr Nicholas Goncalves within one week (seven days), any monies received by me from my medical aid for services rendered by Prof Darlene Lubbe/Dr Nicholas Goncalves.
In the event of divorce the parent accompanying the minor is responsible for the settlement of the account.
In the event of any legal action being instituted against me for recovery of any amount whatsoever, I shall be liable for all legal costs incurred including admin costs, 25% receipting fee. If the matter should be defended, I will be liable for legal costs on an attorney/client scale. The policy of the operation of this practice has been explained to me verbally.
Once the account has been handed over – NO FURTHER CONTACT WITH OUR OFFICES WILL BE PERMITTED.
The National Credit Act 34 of 2005 is not applicable to this claim.
I confirm that the above information is true and correct. I undertake to inform Prof Darlene Lubbe's/Dr Nicholas Goncalves’ office of any changes thereto within 14 days of any change occurring.
Any appointments not kept or cancelled less than 24 hours prior will be charged for.
I accept that fees higher than the National Reference Price List might be charged and I accept the fees charged by the Practice.

Consent

I confirm that the above information is true and correct

Date