Patient Details
Surname: _______________________________ Initials: ______________ Title: _______________________ First Names: ______________________________________ ID number: ______________________________ Home Tel: ____________________ Work Tel: ____________________ Cell: _________________________ E-mail address: ___________________________________________________________________________ Postal address: ____________________________________________________________________________ ______________________ Code:________________ Physical address: ______________________________ ________________________________________________________________Code: ____________________ Occupation: ___________________________________ Employer: _________________________________ Employers address: ________________________________________________________________________ _________________________________________________________________________________________ Medical aid details
Medical aid name: _________________________________________________________________________ Option: __________________________________ Medical aid number: ______________________________ Main member: _________________________________ ID number: __________________________________ Next of kin/Relative
Full Name: ________________________________________________________________________________ Relationship: ______________________________________________________________________________ Home Tel: ________________________ Work Tel: _____________________ Cell: ____________________ E-mail address:____________________________________________________________________________ Medical History
Do you suffer from any of the following? Are you allergic to iodine or any other medication? Y N If yes, what medication are you allergic to? ______________________________________________________ Have you ever had local anaesthetic? Y N Are you on Warfarin or any other anti-coagulant? Y N What medication are you taking at present? ______________________________________________________ _________________________________________________________________________________________ Kindly Note
• This practice does not submit accounts to medical aids. It is your responsibility to settle your account in full. You will be provided with a detailed statement and proof of payment to submit to your medical aid for reimbursements. Payments may be made by means of credit card, debit card or cash. • Price increases may be levied from time to time • Devices can take between 2-3 weeks to manufacture as they are custom made • The device may need adjustment after fitment • Alternative footwear may need to be considered Appointments not kept or cancelled at least 12 hours before will be billed at a full consultation rate
Important Notice
I understand that I am fully responsible for my account and not my medical aid. I understand that I am to settle Please note that if payment is not made within 60 days, the account will be handed over to our attorneys for collections. You will be held liable to pay any collection and/or attorney fees on the Attorney Client Scale. Name: _________________________Signature: ____________________ Date: _______________

Source: http://www.feetfirst.co.za/Joanne-Pereira-History-form-2.pdf


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