CONSULTATION FORM

Patient Details:

Principle Member Details:

Next of Kin Details: (Not the same as above)

Referred by:

Medical Aid Details:

INFORMATION REGARDING CONSULTATIONS

• All consultations: As per your medical aid rate or R1240.60 (Standard Discovery rate) for private patients.
• 90min couples Session: R2000 investment.
• Certain medical aid schemes do not cover psychological consultations. It is therefore the responsibility of the client to settle all outstanding accounts.
• Appointments not cancelled 24 hours before the appointed time will be charged to your account.
• Accounts are payable 30 days net.
• The undersigned shall be liable for any legal proceedings instituted for the recovery of any overdue payments, including all legal charges on the scale as between attorney & his client.
• Consent is hereby given to this practice to allocate an ICD-10 diagnosis on the client’s account as required by medical aids from 1 January 2006.
• NOTE: This information will be shared with a medical billing bureau called Data Spot-On where your information will securely stored in line with South African POPI act. This is for billing purposes only and won't be shared or used for any other purpose.