We kindly request all patients to complete and print the form below. Please bring the completed form with you on the day of your appointment. Patient Particulars Surname: Full names: Initials: Title: Patient ID No: Occupation: Age: Pregnant: YesUnsureNo Allergies: Ref. Dr: General Practitioner: I hereby give consent for the administration to me of contrast medium and/or drugs which may be necessary or required in order to conduct a radiological examination in respect of my person.I acknowledge and agree that I remain personally responsible for payment of all amounts due to the practice. I agree that it is my duty at all times to ensure that my accounts are paid on due date for payment thereof.I hereby give consent to the practice to disclose my ICD-10 status to my medical aid and any other third party in order to obtain payment of any amount owing by me to the practice.I acknowledge and agree that, should a radiologist not be present at the time my X-rays are taken, I irrevocably undertake to procure a radiologist's report regarding my X-rays from the practice as soon as possible after the X-rays are completed, failing which I agree that the radiologist and the practice shall in no way whatever be responsible for any diagnosis made with the use of any such X-rays.I confirm that all the information contained herein is true and correct.Signature: ............................................................................Date: ............................................................................ Account To: Surname: Initials: Title: Residential Address: Postal Address: Employer: Employer Address: Cell.: Tel.: (Home) Tel.: (Work) E-mail Address: Medical Aid Main Member: Main Member ID No.: Name of Medical Fund: Medical Fund No.: PlanOption: Dependant Code Of Patient: Next Of Kin Name and Surname: Address: Tel: Injury On Duty Date of injury: Radiographer Use Only Amount Paid: Receipt: Date: Time: History: Examinations & Protocol: Portable: YES NO Time: Radiographer: Ref. Dr.: Call Dr: YES NO Time: Please enter the text from the image above in the textbox below.