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Patient's Particulars

Next of kin Particulars

Particulars of person responsible for payment of services rendered / Main member of Aid

Please show your medical aid card to receptionist for copy purposes.

I hereby declare that all above-mentioned information is just and true and I accept all responsibility for payment of any legal expenses due to non-payment of any accounts on attorney and client scale. I understand to inquire if I don’t receive an account for services rendered. I will settle the account if it is not paid by my medical aid.

I am also aware that the practice can charge fees above the prescribed medical aid tariffs (RPL). I am aware that the RPL tariffs and values are available from the Department of Health (012 312 0000) and by the Health Professions Council of South Africa (012 338 9300) and at

Account Enquiries: 
Partner4Life, PO Box 29550, Danhof, 9310
Tel nr: (051) 430 0685 
Fax: 086 669 9819

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