Patient Registration Form – Shoulder Surgeon South Africa

Patient Registration Form

Complete the online registration below to speed up your consultation process during your first visit at Dr Hannes Van Der Westhuizen

Full Name & Surname + ID Number *

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Initials + Title *

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Gender + Home Language *

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Contact Numbers *

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Date Of Birth *

Work Number + Email Address *

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Email Statements *

Postal Address Details *

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Physical Address Details *

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Medical Scheme Details *

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Member Details *

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PATIENT INFORMATION *

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Initials + Gender *

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Title + Date Of Birth *

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Home Language + Mobile Number *

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Use this Number for Appointments / Test Results (Main Member's Cell number will be used if down below is No) *

Home + Work Number *

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Email Address + Occupation *

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Marital Status + Relationship to Main Member *

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Patient DEP Code + Age *

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Height + Weight *

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Referring Doctor + Tel Number *

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NEXT OF KIN (Not from same physical address) + Marital Status *

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Initials + Title *

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Relationship to Patient + Cell Number *

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I confirm the Information I supplied is true and I am responsible for any false information provided *

Name in print + Date of Electronic Signature *

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Digital Signature *

Preferred Appointment Date + Time *

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I hereby declare that all above-mentioned information is just and true and I accept all responsibility for payment of any legal expenses due to non-payment of any accounts on attorney and client scale. I understand to inquire if I don’t receive an account for services rendered. I will settle the account if it is not paid by my medical aid. *

I hereby have read and accept the above mentioned clause

All fields with *are mandatory. Please note that you (or your parent/gardian) remain liable for the account for services rendered by this practice, even if you insured by a medical aid or other third party. Please ensure that you have read and signed the attached Doctor-Patient contract

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