FIRST VISIT FORM ADULT PATIENT


Please fill out the form below:
Please place N/A in any blank fields as ALL fields must be entered for the form to be accepted

Patient Medical History:

Person Responsible for account:

MEDICAL QUESTIONAIRE

Patient Ocular History:
Please tick either YES or NO for the following questions.
If you tick yes please provide details
If you checked no then enter N/A under details
If you are unsure of the question check no and enter "Unsure" under details


Yes No
Yes No
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Yes No
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Yes No
Yes No
Yes No
Yes No
Patient Medical History:

Yes No
Yes No
Yes No
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Yes No
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Yes No
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Yes No
Family History: (does anyone in your immediate family have any of the below)

Yes No
Yes No
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Yes No
Yes No
I, the undersigned do hereby ACKNOWLEDGE:
  1. That all fees must be settled immediately after each consultation, and that I will be liable for payment of the fees plus interest calculated from the date of default at the rate determined by law. I further acknowledge that any legal costs incurred by the doctor on account of legal action instituted to recover any outstanding fees from me, will be for my account.
  2. That a statement reflecting my full payment will be issued and it is my duty to submit it to the medical aid for reimbursement.
  3. Accept that each consultation visit is charged for separately.
  4. That it is my responsibility to obtain authorization from my service provider for all procedures.
  5. Accept that any and all appointments not kept will be charged for in full
  6. Give permission for a medical report to be provided to the referring optician/ medical doctor.
  7. We are a cash practice and all consultations must be paid via cash or credit/debit card after the consultation
BILLING POLICY 2020
  • FIRST CONSULTATION/YEARLY FOLLOW-UP: R1750.00.
  • FOLLOW- UP CONSULTATION WITHIN 3 months: R700.00 per consultation
  • FOLLOW- UP CONSULTATION 4-11 months: R1200 per consultation
  • No telephonic consultations will be conducted.
  • In an emergency please present yourself or your child to the nearest Hospital casualty department.
Signature:



Agree
Busamed Modderfontein Private Hospital Orthopaedic & Oncology Centre
4 Cransley Crescent, Long Lake, Sandton, 2090 | Tel: / or

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