Patient Registration Form – Shoulder Surgeon South Africa

Online Appointment

Registration Form

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

Patient Registration Form : Main Member Information

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

Where Did You Heard About Us?

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