Patient Registration Form

Title

First Name*

Gender

Date of Birth

Occupation

Tel Number

Cellphone Number*

Home Address

Postal Address

Medical Aid Details

Name

Members Name

Membership Number

Nearest Family/Friend

Name

Relationship

Telephone Number

Address

Referred by

Name

Telephone Number

Address

Family Doctor

Name

Telephone Number

Address

Please answer all the below questions

1. Have you been in hospital during the last 2 years? *

2. Have you been treated by a doctor in the last 2 years? *

3. Have you undergone any operations? *

If yes, please specify:

4. Are you pregnant? *

5. Are you currently under medical treatment? *

6. Do you use any medication? *

If yes please specify

7. Do you take disprin or any other anti-coagulant medication? *

If yes please specify

8. Do you suffer from any allergies? *

If yes please specify

Have you ever, or are you suffering from any of the following?

Jaundice
Epilepsy

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.

Date

Patient
Parent
Guardian

Terms and Conditions understood*

Patient Details

Declaration