New Patient Documents

New Patient Information

Main Member Information

Title

Name *

First

Last

Email *

Phone *

ID or Passport Number *

Birth Date *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Information

Name *

First

Last

Mobile Number for Results/Appointments *

Patient Date of Birth

Relationship to Main Member

Patient Dependent code

Medical Aid Information

Medical Aid Provider

Medical Aid Plan/Option

Medical Aid Number

Main Member Dependent Code

Next of Kin

Full Name of Next of Kin

Mobile Number of Next of Kin

Relationship to Main Member

Referring Doctor

Referring Dr Name

Dr Tel Number

Supporting Documents

Copy of ID *

Drag & Drop Files, Choose Files to Upload

Medical Aid Card *

Drag & Drop Files, Choose Files to Upload

Proof of Residence *

Drag & Drop Files, Choose Files to Upload

Confirm Responsibility *

It remains your responsibility to inform and update all personal and medical detail information with the practice and that you undertake to keep the practice regularly informed with regards to any changes to your contact details, medical and membership, and list of dependents.

Accept Medical if on Medical Aid *

The abovementioned is true the best of my knowledge. I authorize my medical aid benefits to be paid directly to the physician. I understand that I am financially responsible for the balance. I also authorize Dr GJM Wolmarans or medical to release any information requires to process my claims.

New Patient Documents

New Patient Information

Main Member Information

Patient Information

Medical Aid Information

Next of Kin

Referring Doctor

Supporting Documents

Dr GJM Wolmarans

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