PATIENT DETAILS

PERSON RESPONSIBLE FOR ACCOUNT

MEDICAL AID

NEXT OF KIN

REFERRED BY

FAMILY MEMBERS

Names

Date of Birth

Allergies

Comments

This account remains your responsibility until fully paid. Regular follow-ups by the member with the medical ald may be required to ensure prompi payment. In the case of your medical aid not paying the full account you will be liable for the balance.

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Pre-Consultation Information Questionnaire

1. Have you previously been diagnosed by someone else with any of the following:


2. Where in your body is the pain you are coming to see me about:


3. A BRIEF history - in order (not too much detail) of what you have already done for the pain

Click to download Financial Policy Document


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