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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
Wear glasses/contacts now/past:
Yes
No
Ocular medication:
Yes
No
Previous strabismus: (squint)
Yes
No
Previous amblyopia: (lazy eye)
Yes
No
Previous eye surgey :
Yes
No
Glaucoma:
Yes
No
Cataracts:
Yes
No
Retinal disease:
Yes
No
Diabetic eye disease:
Yes
No
Corneal problems:
Yes
No
Other:
Yes
No
Double vision:
Yes
No
Patient Medical History:
Medications:
Yes
No
Allergies:
Yes
No
Respiratory problems: (e.g. asthma)
Yes
No
Heart problems:
Yes
No
Hematologic problems: (anemia, bleeding, etc.)
Yes
No
Kidney or Urinary Problems:
Yes
No
Neurologic Problems: (headaches, seizures, hydrocephalus etc.)
Yes
No
Infectious diseases:
Yes
No
Endocrine Problems: (diabetes, thyroid, etc.)
Yes
No
Rheumatological disease: (arthritis etc)
Yes
No
Cancer:
Yes
No
Problems with anaesthesia:
Yes
No
Other:
Yes
No
Previous surgery:
Yes
No
Family History: (does anyone in your immediate family have any of the below)
Diabetes:
Yes
No
Thyroid disease:
Yes
No
Strabismus or lazy eye:
Yes
No
Heart disease:
Yes
No
High blood pressure:
Yes
No
Other:
Yes
No
I, the undersigned do hereby ACKNOWLEDGE:
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.
That a statement reflecting my full payment will be issued and it is my duty to submit it to the medical aid for reimbursement.
Accept that each consultation visit is charged for separately.
That it is my responsibility to obtain authorization from my service provider for all procedures.
Accept that any and all appointments not kept will be charged for in full
Give permission for a medical report to be provided to the referring optician/ medical doctor.
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
By ticking the box below the electronic signature, you acknowledge that you have signed the document electronically and have agreed to the terms and conditions
Submit
Busamed Modderfontein Private Hospital Orthopaedic & Oncology Centre
4 Cransley Crescent, Long Lake, Sandton, 2090 | Tel:
011 458 2027
/
8
or
0724674639
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ABOUT DR CLAIRE CULLEN
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