Blouberg's Patient Information Form Main Member Information ID Number* Surname* First Name* Initials* Title* Male or Female* Male Female Your Age* Date of Birth* Mobile Number* Work Number* Employer* Email Address* Email Statements* Yes No Postal Code* Postal Address* Home Address Medical Scheme Scheme Plan/ Option Medical Scheme Number Gap Cover Yes No Medical Aid (If applicable) Medical Scheme Plan/ Option Member Number Patient Information (Please fill in all fields if different from main member) First Name Surname Initials ID Number Male or Female Male Female Initials Title Mobile Number Work Number Email Address Occupation Relationship to Main Member Patient Dependent Code GP/ Referring Doctor Referring Doctors Number Patient Medical History Chronic Conditions Allergies Previous Operations Medication Blood Thinners Yes No If yes, please specify Next of Kin (Not living at the same physical address) Surname* Initials* Title* Relationship to Patient* Contact Number* Email Address* Disclaimer Disclaimer* Hereby I confirm that the information I supplied is true and I am responsible for any false information provided. All fields with * are mandatory. I take full responsibility for the account for services rendered by this practice, even if I am insured by a medical aid or other third party. I take note of the fact that, in the event of non-payment within 90 days, my name will be listed on “ITC”, a national data base of slow payers. By accepting these terms and conditions you agree to our Protection of Personal Information Act (POPIA). Here at Dr Mark van der Kaag's practice, we take our client's privacy seriously and we would like to ensure that we have your consent to keep sending email communications to you. If you are happy to stay on our mailing list to receive our special offers and announcements, no action is required. Should you no longer wish to be part of our mailing list, contact us directly to be unsubscribed. Thank you for your continued support! I have read and understand the billing policy. I accept terms & conditions Your Signature* Select a date* Submit
