Patient Details

Medical Aid Details
Nearest Family/Friend
Referred by
Family Doctor
Please answer all the below questions

Declaration

I declare the above information is correct. I also understand that this practice has no agreement with any medical aid scheme for direct invoicing and take responsibility for settlement of the account. The undersigned signatory to this schedule binds himself/herself as surety and co-principal debtor for the punctual payment, by the patient and/or the person responsible for the account, of all amounts due to Dr Hans Van Heerden. In the event that it becomes necessary to institute legal proceedings to enforce payment of any amount due to Dr Hans Van Heerden, the party liable therefore shall pay all the fees and disbursements in connection therewith on the scale between attorney and own client. Appointments not cancelled within 24 hours will be charged.