KZN - Returning Patient Form

Returning Patient Form

To ensure your forms are successfully submitted please ensure ALL the spaces are completed.

If something is not applicable to you kindly complete with NA.

Patient Information

Name :(Required)

Surname :(Required)

Age(Required)

ID Number :(Required)

Gender(Required)

Date of Birth :(Required)

Home Language :(Required)

Email Address :(Required)

Contact Number :(Required)

Work Number :(Required)

Occupation :(Required)

Employer :(Required)

Residential Address – full address required including postal code.(Required)

Marital Status(Required)

Referring Doctor :(Required)

Partner Information

Name :(Required)

Surname :(Required)

Age(Required)

ID Number :(Required)

Gender(Required)

Date of Birth :(Required)

Home Language :(Required)

Email Address :(Required)

Contact Number :(Required)

Work Number :(Required)

Occupation :(Required)

Employer :(Required)

Residential Address :(Required)

Marital Status(Required)

Referring Doctor :(Required)

How did you hear about us?(Required)

MEDICAL AID INFORMATION - MAIN MEMBER / PERSON RESPONSIBLE FOR THE ACCOUNT

MAIN MEMBER / PERSON RESPONSIBLE FOR THE ACCOUNT

Title :(Required)

Name :(Required)

Surname :(Required)

ID Number :(Required)

Date of Birth :(Required)

Medical Scheme :

Member Number :

Plan / Option :

Dep Code :

Gap Cover :

MEDICAL AID INFORMATION - IF DIFFERENT FROM MAIN MEMBER

IF DIFFERENT FROM MAIN MEMBER

Title :

Name :

Surname :

ID Number :

Date of Birth :

Medical Scheme :

Member Number :

Plan / Option :

Dep Code :

Gap Cover :

MEDICAL HISTORY

Are you taking any supplements / vitamins / homeopathic medication:(Required)

If yes, please list:

Any new allergies?(Required)

If yes, please list:

Any new medical conditions / problems we need to be aware of?(Required)

If yes, please list:

Any recent surgical procedures that have been done(Required)

If yes, please list:

Please note that you (or your parent/guardian) remain liable for the account for service rendered by this practice, even if you are insured by a medical aid or other third party. Please ensure that you have read and signed attached Doctor-Patient contract. This practice basis its fee structure on that set out be the Medical Association of South Africa and does not conform to “Medical Aid Rates.” This means that you are personally responsible for the payment of your account. If you are a member of a Medical Aid Scheme, you may claim reimbursement from your society once you have settled your account with us. Payments is to be made at our offices directly after each visit. Medication will not be released without payment. We accept all credit cards as well as cash.

I, undersigned, do hereby agree that:

1. Payment of the account in accordance with the tariff of charges prevailing in the practice shall be the responsibility of the undersigned / patient.
2. In the event of an account not being timeously settled in full, interest at the prevailing rate will be charge until the account has been settled.
3. I undertake to be liable for all legal costs between attorney and clients as well as collection fees due. Should it be necessary for any legal action to be taken for the recovery of any amounts owning / arising out of treatments received by the above patient.
4. Further consent is given to enable Vitalab to obtain credit and related information concerning myself, at any time and to lodge, exchange, disclose such information with any credit bureau without further notice to me.

Banking Detail: EFT (TRANSER FROM RSA BANK ONLY)
ELECTRONIC TRANSER: Vitalab Kwazulu Natal Operations (Pty) Ltd
BANK : Investec
Branch : Grayston Drive, Sandton
Account No : 10012554123
Swift Code: IVESZAJJ
Foreign Transfer: To reduce forex / bank charges complete the debit / credit instruction form

WalletDoc : https://www.walletdoc.com/pay/VitalabKZN

Proof of payment together with this form must be sent to reception@vitalab.com. Confirmation of our appointment will be made via email once your payment reflects on our bank statement (about 2 - 3 days after payment is made.) Please use FULL NAME and SURNAME given to reception as your reference or we will not be able to confirm your appointment. I hereby I confirm that the information I supplied is true and I am responsible for any false information provided.

Name:(Required)

Date of agreement :(Required)

Returning Patient Form

Patient Information

Partner Information

MEDICAL AID INFORMATION - MAIN MEMBER / PERSON RESPONSIBLE FOR THE ACCOUNT

MEDICAL AID INFORMATION - IF DIFFERENT FROM MAIN MEMBER

MEDICAL HISTORY

Gauteng

Kwa-Zulu Natal