Badenhorst & Foot New Patient Form

    Patient Particulars

    Main Member / Person Responsible for Account

    Medical Aid Details

    Agreement
    Patient Particulars

    Main Member / Person Responsible for Account (If similar than patient details, please move to the next step)

    Medical Aid Details

    I declare all information is as correct and true I understand that this practice collects, stores, uses, processes, transfers, archives, and otherwise manages Personal Information. In order to discharge this duty, I express and give informed consent to collect and process my Personal Information or that of my dependant. I give consent to the practice of sharing my Personal Information with selected healthcare providers, medical schemes, administrators, services providers, and any third parties necessary for the provision of any service to me. I understand and agree that if the practice does not have my or my dependents consent, the practice will not be able to commence treatment, and cannot share my Personal Information with any specialist/sub-contractors/other providers to optimise my healthcare treatment I understand that my Personal Information will be stored electronically or in a hard copy in a safe and secure environment. Hard copies will be stored and retained safely under lock and key. After I am no longer an active patient, my Personal Information will be retained for as long as law or practice indemnity/ insurance providers require it I hereby give permission that physiotherapy modalities may be performed on me by Badenhorst & Foot physiotherapists. I hereby give permission for the removal of any clothing that may restrict treatment as necessary. I hereby give permission that treatment may be altered during the course of the session, as decided by the physiotherapist. I understand the risks involved in following an exercise program and take full responsibility thereof. I take note of the fact that the full tariff may be charged if any appointment is not canceled within two hours, prior to the appointment time. Medical aid schemes do not pay for these unattended appointments and it remains my responsibility. I agree that should my account be handed over for collection, I shall be liable for all attorneys and own client fees, collection charges, and all disbursements. I understand that the practice contract is with me and not my medical aid, insurer, workmen’s compensation, or road accident fund, therefore all payments of the account remain the responsibility of the patient, or his parents/ legal guardian in the case of a minor I agree that the account and payment of the account are subject to the Prescribed Rate of Interest Act and that I remain liable for more interest on accounts that have not been settled within 60 days. Change of information must please be done as soon as possible Appointments must be kept on time