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

Main Member

(Person responsible for payment)

Medical Aid

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

Nearest family or friend

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.