016 110 0602
016 933 4011
info@ardiagnostics.co.za

Patient Personal Information

Please fill in all information

Person Responsible for Account

Medical Aid Main Member Information

Please fill in all Medical Aid Details

  • Patient Information
  • Main Member
  • Medical Aid Details

Information

Title

Initials

Dep. Code

Full Names

Surname

Language

Gender

I.D. Number

Date Of Birth

Employer

Home Number

Work Number

Cell Number

Email Address

Medical Information

Previous Operations or Contrast Examination

Allergies?

Ref. Doctor

Auth. No.

Smoking?

Are You Pregnant?

Asthma?

Are you Breastfeeding?

High Blood Pressure?

Kidney Failure?

Main Member Inform

Title

Initials

Dep. Code

Rel. to Patient

Full Names

Surname

ID Number

Date of Birth

Home Number

Work Number

Sell Number

E-mail Address

Postal Address

Residential Address

Employer

Employer

Employers Address

Employee No.

Relative or Friend

Name and Surname

Home Number

Cell Number

Date of Injury

Medical Aid Details

Med. Aid Name

Med. Aid No.

Claim Number

PLEASE NOTE: WE DO NOT ACCEPT RESPONSIBILITY FOR THE LOSS OF VALUABLES. LET WEL: ONS AANVAAR NIE VERANTWOORDELIKHEID VIR VERLIES VAN WAARDEVOLLE ITEMS NIE.

I hereby accept full responsibility for the account and acknowledge that I have read and accept the terms and conditions as printed on the reverse side of this document. Ek aanvaar voile verantwoordelikheid vir die rekening en erken dat ek die voorwaardes soos op keersy van hierdie dokument gelees en aanvaar het.

Accounts

TERMS AND CONDITIONS I hereby declare and warrant that: The information provided is true and correct. • I undertake and promise, notwithstanding any Medical Aid Society or other organisation's undertakings, to pay the account of AR Diagnostics immediately on receipt of the statement. • I agree to pay all and/or any costs, fees and or disbursement incurred by AR Diagnostics for the collection of amounts owing by me which may include tracing costs, debt collectors fees and commission as well as attorney fees and disbursements on the scale of attorney and own client. • I grant consent for any injection and/or other administration of any drugs and/or contrast media which may be necessary for the performance of any medical imaging examination. • I hereby authorise AR Diagnostics who are in possession of information concerning my medical diagnosis and treatment, together with my health and personal particulars to disclose such information to my healthcare funder and other healthcare providers. Permission to disclose such information is only for the purpose of treatment and management of my medical condition. I wish to indicate that this consent is given out of my own free will without any undue influence whatsoever. • I understand that AR Diagnostics shall not be liable, directly or indirectly for any loss, damages, costs and/or expenses directly sustained by me as a result of the services rendered by AR Diagnostics and that I hold them harmless against all and/or losses incurred by me in consequence of any claim arising from the services rendered. • By signing this document I confirm that I am aware that the practice may make the X-ray and other digital images taken by the practice, available in a digital electronic form to medical practitioners, including but not restricted to my medical practitioner. • I consent to such X-rays and other images being made available to all such medical practitioners in a digital/electronic form, and I confirm that I am aware that all such digital/electronic images may be printed out and examined by all such medical practitioners • By signing this document, I confirm that I shall be deemed to have read and understood the terms and conditions contained herein and that I am legally bound thereby.

Terms And Conditions

info@ardiagnostics.co.za
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