Patient Agreement

Please fill in the online form below or if you prefer to download the agreement, please download the following document, fill it in and either submit it here or bring it with you to the appointment

patient_agreement.pdf
File Size:	167 kb
File Type:	pdf

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Patient Agreement

Patient

* Indicates required field

Surname *

Full Names *

Given Name *

Occupation *

Date of Birth *

ID Number *

Telephone (H) *

Cellphone *

Telephone (W) *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Person Responsible For Account

Same as above *

Yes No

Surname *

Full Names *

Date of Birth *

Cell Phone *

ID Number *

Email *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Postal Address *

Line 1

Line 2

City

State

Zip Code

Country

Account management is outsourced to Partner4Life Medical Billing Agency.

Medical Aid Information

Medical Aid *

Main Member *

Member Number *

Plan *

Main Member ID *

Patient Code *

PLEASE TICK THE RELEVANT OPTION: *

Please submit the account directly to my medical aid. I undertake to settle any outstanding fees not covered by them I prefer to pay by card or cash after treatment, after which a statement will be sent to me electronically.

Please note that any pre-authorisation from your medical aid is the responsibility of the member and not of the practice.

PATIENT AGREEMENT:

PASIENT OOREENKOMS

I confirm that the information on my file is correct and agree to notify any change within 14 days and to supply new data accordingly.
I give consent that the practice may claim for treatments directly from my medical aid. I take full responsibility for the account and to pay all money not paid by my medical aid, within 90 days.
Private accounts will be sent via email, and should be settled within 14 days. This also applies when funds from the medical aid has been depleted.
I accept that in the event of my noncompliance with any of the above, my account may be handed over to an attorney/debt collectors and I will be liable for all legal costs, including collection commission and trading fees.
I hereby take note that the physiotherapist may request me to partially undress as necessary for proper evaluation and/or treatment.
I give permission for the physiotherapist to use electrical modalities/apparatus on me during treatment sessions and for her/him to use the appropriate treatment methods she recommends for my specific condition/problem.
Should you not keep to your appointment, you will be liable for a fee, which will be determined by the practice.
Regarding the use of dry needling, please tick one of the following:

Ek bevestig dat inligting op my lêer korrek is en indien enige inligting verander, ek julle binne 14 dae in kennis sal stel van die verandering.
Ek gee toestemming dat die praktyk direk behandelingkodes van my mediese fonds mag eis. Ek neem volle verantwoordelikheid vir die rekening en om alle fooie wat nie deur my mediese fonds betaal word nie, binne 90 dae te vereffen.
Privaatrekeninge sal per e-pos gestuur word en moet binne 14 dae vereffen word. Dieselfde geld indien u mediese fonds voordele uitgeput is.
Ek aanvaar dat indien bogenoemde nie nagekom word nie, my rekening aan ‘n prokureur/invorderaar oorhandig mag word en ek aanspreeklik sal wees vir alle regskoste om gelde in te vorder, asook invorderingskommissie en opsporingskoste.
Ek neem kennis daarvan dat dit van my verwag kan word, om gedeeltelik te ontklee, vir die fisioterapeut om my effektief te kan evalueer en/of behandel.
Ek gee toestemming dat die fisioterapeut elektriese modaliteite/apparaat op my kan gebruik en dat sy my mag behandel met tegnieke, soos deur haar aanbeveel.
Indien u nie vir ‘n afspraak opdaag nie, kan u vir ‘n fooi verantwoordelik gehou word, wat deur die praktyk bepaal word.
In verband met die gebruik van droë naaldterapie, merk asseblief een van die volgende:

Dry needling / Droë naaldterapie *

I am comfortable and give my full consent for the use of dry needling in my treatment, if necessary / Ek is gemaklik met, en gee my volle toestemming vir die gebruik van droë naaldterapie, indien nodig I need more information on dry needling before giving consent for the use thereof in my treatment, if necessary / Ek benodig meer inligting oor droë naaldterapie voordat ek kan toestem tot gebruik daarvan in my behandeling I do not give consent for the use of dry needling in my treatment / Ek gee nie toestemming vir die gebruik van droë naaldterapie in my behandeling nie

By Clicking here you agree that the information is accurate and you sign the agreement

Patient Agreement

Patient Agreement

Patient

Person Responsible For Account

Medical Aid Information

PATIENT AGREEMENT:

PASIENT OOREENKOMS

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