Surname: _______________________________ Initials: ______________ Title: _______________________
First Names: ______________________________________ ID number: ______________________________
Home Tel: ____________________ Work Tel: ____________________ Cell: _________________________
E-mail address: ___________________________________________________________________________
Postal address: ____________________________________________________________________________
______________________ Code:________________ Physical address: ______________________________
Occupation: ___________________________________ Employer: _________________________________
Employers address: ________________________________________________________________________
Medical aid details
Medical aid name: _________________________________________________________________________
Option: __________________________________ Medical aid number: ______________________________
Main member: _________________________________ ID number: __________________________________
Next of kin/Relative
Full Name: ________________________________________________________________________________
Home Tel: ________________________ Work Tel: _____________________ Cell: ____________________
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? ______________________________________________________
• 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: _______________
RECURRENT APHTHOUS STOMATITIS (Recurrent Mouth Ulcers) What are the aims of this leaflet? This leaflet has been written to help you understand more about Recurrent Aphthous Stomatitis (RAS). It tells you what it is, what causes it, what can be done about it and where you can find out more about it. What is recurrent aphthous stomatitis (RAS)? RAS consists of recurrent bouts of one
Microprocessor Systems Unit Value (typically 90 hours for a full-time course) This standard unit is primarily for use by the Technical Institutes when operating the following Course : Diploma in Computer and Communications Engineering (0304) Teaching staff should devise guidance and supervision process to facilitate achievement of the principal objectives. To gain a pass grade, st