Patient Registration / Pasiënt Registrasie


Patient Details / Pasiënt Besonderhede



Male / ManlikFemale / Vroulik

Medical Aid Details / Mediese Fonds Besonderhede


Details of Main Member - Person Responsible for Account / Besonderhede van Hooflid - Persoon Verantwoordelik vir Rekening


Next of Kin / Naasbestaande


Authorisation / Magtiging

I agree that the address above is my chosen domicilium citandi et executandi for purposes of delivering and serving of all invoices, documents and legal processes. I further agree that in the event of medical aid not paying any award due for whatsoever reason, that I am still liable in my personal capacity to pay the amount owing. I further agree that in the event of my account being handed over to attorneys, that I will pay all attorneys fees and costs on attorney and client scale together with further collection commission.

Hiermee bevestig ek dat die bogenoemde adres my domicilium citandi et executandi vir aflewering en hantering van alle fakture, dokumente en by regsprosesse is. Ek bevestig ook dat indien die mediese fonds, vir enige rede nie die fooie verskuldig vereffen nie, ek in my privaat hoedanigheid verantwoordelikheid aanvaar vir alle kollekteringsfooie en regsonkostes vir beide prokureur en kliënt.

I Agree / Ek Stem