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Patient information
This form collects the personal information of the patient that will visit Dr Karlien van Zyl & Associate practice in Stilbaai. We will utilize this information to create your electronic patient file. Please provide us with as much detail information to create a complete file on our system. If you only have a hospital plan also provide the detail of the medical aid plan.
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Patient Surname
*
Your answer
Patient Full Name
*
Your answer
Patient Id Number
*
Your answer
Cellphone number
*
Your answer
Email address
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Your answer
Street Address, Town,
Postal Code
*
Your answer
Medical Aid Name
Your answer
Medical aid option
Your answer
Medical aid number
Your answer
Dependent code
Your answer
Main Member name
Your answer
Main member ID no.
Your answer
Main member's email if not the same as patient
Your answer
Main Member cellphone no. if not the same as patient.
Your answer
We do send claims to your medical aid if benefits are available. However you remain responsible to settle your account
I acknowledge that I am ultimately responsible for settlement.
You hereby provide us with consent in terms of the Protection of Personal Information(POPI) Act, No. 4 of 2013 to process your information and to safekeep it. You are responsible to provide us with any update to your information.
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I provide consent for the processing and safekeeping of my information.
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