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MEDICAL AID


MEDICAL AID MAIN MEMBER INFO:


Husband/Partner/Commissioning Parent (surrogate)


Please read & check the box

  • I have been informed that this practice does not necessarily charge the rates that my medical scheme may have decided upon.
  • I am fully responsible for payment of services rendered by dr. Pistorius and for appointments not cancelled 24 hours in advance.
  • Should I not pay timeously, understand that I will be liable for debt recovery costs on an attorney and own client scale.
  • I agree that the report will be sent to the doctors mentioned above, and that they give feedback regarding the pregnancy outcome.
  • I agree that my invoice will be completed with all relevant ICD-10 diagnostic codes.

You will receive confirmation from the office when this form is processed.