Patient Form – Cape Town Dermatologists

PATIENT DETAILS FORM

TitlePlease select your preferred title

SA Identity number/Passport number *Please enter your SA Identity number or passport number for non-SA citizens

First name *Please provide your first name

Surname *Please provide your surname

Email AddressPlease provide your email address

Contact number *Please provide your preferred contact number

Street Address *Please provide your residential address

Apartment, Complex, etc

City

Province

Postal Code

Country

Title

SA Identity number/passport number

First namePlease provide the name of the main member

SurnamePlease provide the surname of the main member

Contact numberPlease provide the contact number of the main member

Email AddressPlease provide the email address of the main member

Medical Aid NamePlease enter the Medical Aid Name

Plan/OptionPlease enter the Medical Aid Plan

Medical Aid NumberPlease enter the Medical Aid Membership number

I herewith agree to the terms and conditions described bellow:

All fees must be settled on the day of the appointment.
Any additional procedures will be at an extra cost.
Our fees are above medical aid rates and we are not contracted into medical aid.
I, do hereby agree to pay all legal fees and collection costs in the event of delayed payment of my account.