MEDICAL AID

Medical Aid *

Your Medical Aid Number *

Medical Aid PLAN *

MAIN MEMBER: Name *

MAIN MEMBER: ID number *

Patient Dependent code

Surname and initials *

Title *

Name *

ID number/Date of birth *

Email *

Cel *

Occupation *

Terms & Conditions *

Please read & check the box

I have been informed that this practice does not necessarily charge the rates that my medical scheme may have decided upon.
I am fully responsible for payment of services rendered by dr. Pistorius and for appointments not cancelled 24 hours in advance.
Should I not pay timeously, understand that I will be liable for debt recovery costs on an attorney and own client scale.
I agree that the report will be sent to the doctors mentioned above, and that they give feedback regarding the pregnancy outcome.
I agree that my invoice will be completed with all relevant ICD-10 diagnostic codes.

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