SURNAME *
FULL NAMES:
I.D.NUMBER:
MARITAL STATUS:
DATE OF BIRTH:
DEPENDANT CODE OR NUMBER:
OCCUPATION
HOME LANGUAGE
POSTAL ADDRESS
RESIDENTIAL ADDRESS
EMPLOYERS NAME
TEL (W)
TEL(H)
CELL NO
FAX NO
FAX TO MAIL
E-Mail Address (Home)
E-Mail Address (Work)
Name
IDENTITY NUMBER
EMPLOYER
TELEPHONE NUMBER
Email @ Home
Email @ Work
ADDRESS OF SPOUSE/PARENT EMPLOYER
MEMBER NAME
MEDICAL AID
PLAN TYPE
MEMBER MED AID NUMBER
DOES YOUR PLAN TYPE COVERS PRIVATE GYNAECOLOGPRIVATE HOSPITALS ?
Yes
No
Some Medical Aids do not pay for private gynaecology and private hospitals services, but only pay gynaecology at state hospital .It is your duty to ensure that your medical society covers or you will be declared private patient.
1. Name
Address
Relationship
CELL
2. Name
Please note this practice is not contractually bound to any medical aid. We determines our rates according to accepted legal frame work . Feel free to discuss with us about charges. The patient is responsible for any amount which your medical aid does not pay.
