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Husband/Partner/Commissioning Parent (surrogate)

Please read & check the box

  • I am aware 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 or dr Venter (practicing in association) 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 hereby consent to the processing of my personal information contemplated in the Protection of Personal Information Act (act no 4 of 2013) by dr. Pistorius or dr Venter, their locum tenens or practice staff and third parties for the following purposes:
    • Treating and managing me in terms of a doctor-patient relationship;
    • The administration of the contractual relationship between myself and dr. Pistorius or dr Venter;
    • Communicating with other persons inasmuch as it relates to my treatment and management (including but not limited to providing reports to my attending physician; obtaining information relevant to the current or planned pregnancy, and feedback on current pregnancy);
  • Communicating with third parties who have undertaken to indemnify me for the costs of my treatment and management or part thereof including medical schemes and their administrators where relevant; and
  • Collecting monies outstanding from me.

You will receive confirmation from the office when this form is processed.