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New Booking
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FAQ’s
Contact Us
Patient Information
BioLogic Health
Patient Information
Please complete and submit
PATIENT DETAILS
ID Number
Patient Surname
Patient Full Names
Patient Nickname
Initials
Title
Mrs
Mr
Ms
Miss
Master
Rev
Prof
Insp
Dr
Const
Adv
Date of Birth
Gender
Female
Male
Other
Home Language
Marital Status
Married
Separated
Divorced
Widowed
Single
Patient Occupation
Employer
PATIENT CONTACT DETAILS
Physical Address
Suburb, Town
Postal Code
Postal Address
Patient Home Number
Patient Work Number
Patient Cell Number
Patient Skype Address (if relevant)
Patient Email Address
Consent to Receive Communication
I hereby give consent for the practice to correspond with me regarding my appointment dates, results, scripts and medications prescribed.
I agree
I do not agree
Preferred Method of Communication:
Email
Whatsapp
Phone calls
sms
I hereby give consent for the practice to send me general information and periodic updates. I understand that I can unsubscribe at any time.
I agree
I do not agree
MEDICAL AID DETAILS
Please complete this section if you would like us to add these details to your invoice so that you can claim back part of your consultation from your medical aid according to your plan or option.
Medical Aid Scheme
Membership Number
Medical Aid Plan
Medical Aid Option
Main Member Name and Surname
Main Member Title
Master
Miss
Mr
Mrs
Ms
Main Member Gender
Main Member Date of Birth
Main Member ID Number
Main Member Email Address
Main Member Contact Number
Patient Dependant Code
Please provide your Next of Kin (not living with you) details.
Name and Surname
Relationship
Physical Address
Contact Number
AGREEMENT
This practice charges private rates in accordance with those outlined by the Board of Healthcare Funders (BHF).
Please note that this practice is not contracted to any medical schemes, and we do not submit any medical aid claims.
All accounts must be settled in full after each visit. Payment will be accepted in the form of Cash, Snapscan, Debit or Credit Card.
Select Here to Agree
I, the Patient, acknowledge that I have read and understood this statement and agree to the terms and conditions laid out in it.
CONFIDENTIALITY
To provide you with the best possible service, your relevant personal information will need to be collected and recorded on file. This is important and necessary to document details of your medical consultations to allow the doctor to refer to your history, track changes and provide you with professional care and advice.
We undertake to keep all notes confidential in line with the requirements of the POPI Act and provide assurance that they will not be shared or discussed without your permission.
Some information may be used for research purposes and case studies; however, this will remain anonymous, and your privacy will be respected at all times.
Select Here to Agree
I, the Patient, acknowledge that I have read and understood this statement and agree to the terms and conditions laid out in it.
CONSENT FOR ELECTRONIC STORAGE OF HEALTH RECORDS
I Hereby give Consent for my medical doctor to capture and store all Personal Information relating to my health records and that of my medical aid dependants, including names, identity numbers, and other Personal Information, along with details of our medical treatment, medications, medical appointments, procedures and medical aid claims in his/her patient database and practice management system.
I confirm that I am authorised to give such consent on behalf of my medical aid dependants. I understand that this Personal Information may be stored either on site at the practice, or else off-site in a secure encrypted cloud environment managed by a third party.
Select Here to Agree
I, the Patient, acknowledge that I have read and understood this statement and agree to the terms and conditions laid out in it.
CONSENT FOR LIMITED SHARING OF HEALTH RECORDS
I Understand that my/our doctor may need to share my/our Special Personal Information with healthcare service providers, for example medical aid schemes, healthcare facilities, insurers, administrators, and pharmacists, for the purpose of providing me/us with comprehensive, integrated health services and for conducting member checks.
I understand that from time to time my medical doctor may allow a computer specialist to access his/her patient database which carries my/our Personal Information for the purpose of updating or repairing the database. I give permission for such temporary sharing, on the understanding that the practice has signed Data Processing agreements with such third parties.
I understand that my/our special Personal Information will not be shared with any other third party by my/our medical doctor without my/our express, specific, prior permission.
Select Here to Agree
I, the Patient, acknowledge that I have read and understood this statement and agree to the terms and conditions laid out in it.
DECLARATION: Select this Box to Agree
I, the patient, remain fully liable for all accounts and will settle the account immediately.
DECLARATION: Select this Box to Agree
If I do not keep my appointment or cancel less than 2 hours prior to the appointment, I undertake to pay the full consultation fee.
DECLARATION: Select this Box to Agree
I, the Patient , declare that all the information entered into this form is correct, and I will update my details with each appointment.
DECLARATION: Select this Box to Agree
I, the Patient (as signed below), have read and understood the terms of this Agreement.
Signed at
Signed on
Year
Patient Electronic Signature
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