Patient Information Form

Hereby I confirm that the information I supplied is true and I am responsible for any false information provided. All fields with * are mandatory. I have read, understand and agree to the conditions mentioned above. I confirm that the information provided by me is true and correct. I take full responsibility for the account for services rendered by this practice, even if I am insured by a medical aid or other third party. By signing this form, I agree that I have been provided with a copy of the practice’s billing policy, that I have read the policy and understand the contents of the policy and the manner in which the practice bills. In the event of divorce, the parent accompanying the minor is responsible for settlement of the account. Cancellations made with less than 3 hours notice from the start of the appointment time and no shows will be charged as per the practice rates. If I arrive late for the appointment I understand that the appointment duration will be shortened or need to be rescheduled if insufficient time at my own cost. In the event of any legal action being instituted against me for recovery of any amount whatsoever, I shall be liable for all legal costs including admin costs. If the matter is defended, I will be liable for legal costs incurred on an attorney/client scale. Once my account has been handed over there will be no further correspondence entered into with the practice. The National Credit Act 34 of 2005 is not applicable to this claim. I hereby choose my above address as my domicilium citandi et executandi for all purposes under this agreement. I take note of the fact that, in the event of non-payment within 90 days, my name will be listed on “ITC”, a national data base of slow payers. By accepting these terms and conditions you agree to our Protection of Personal Information Act (POPIA). Here at Dr. Bianca Leigh Edward's practice, we take our client's privacy seriously and we would like to ensure that we have your consent to keep sending email communications to you. If you are happy to stay on our mailing list to receive our special offers and announcements, no action is required. Should you no longer wish to be part of our mailing list, contact us directly to be unsubscribed. Thank you for your continued support! Medical Aid and Payment details FAQ.