Patient Forms

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:
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:

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