Patient information

This form needs to be completed for administrative purposes. Please note: We only accept EFT payments at this stage. You will recieve an invoice straight after your consultation with your dietitian. Please pay within 24 hours of your session. Thank you.

Patient information

Title

First Name

Initials

Last Name

ID Number

Sex

Male

Female

Date of birth

Language

Age

Tel no (H)

Tel no (W)

Cell

Email Address

Residential address of patient

Postal Code

Occupation

Employer name

Main Member

(Person responsible for payment)

Payment Type

Medical aid

Cash

EFT

Title

Name and Surname

ID Number

Relationship with patient

Referring doctor

Reason for referral

Employer name

Residential address of patient

Postal Code

Tel no (H)

Tel no (W)

Cell

Medical Aid

Please complete the following in order to address your account to the medical aid: Very important to complete this part in FULL

Name of medical aid

Medical aid number

Plan

Dependant code

Nearest family or friend

Name and Surname

Relationship

Tel no (H)

Tel no (W)

Cell

Address

Postal Code

I hereby accept full responsibility for payment of all outstanding amounts due to Nicola Mostert T/A 4Life Living Dietitians for services rendered to me or my family. In the event of my medical aid fund rejecting claims forwarded to them I further accept full liability for the outstanding balance of such accounts. Terms are 30 days treated as cash and interest at the monetary rate on all overdue amounts. I understand that I will also be liable to pay collection commission, legal costs and all other costs of collection, agents, should we have to resort to such means to claim overdue amounts from me. A service fee of R120.00 will be added to all accounts handed over to our debt collectors firm, Duvesco.

I declare that all information is true and I agree to the agreement

Yes

Patient information