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Internal Contact Form

Personal Information

Gender

Contact Details

Physical Address
Physical Address
City
State/Province
Zip/Postal
Country

Section

Postal Address same as Physical Address
Postal Address
Postal Address
City
State/Province
Zip/Postal
Country

Medical Aid

Do you have a Medical Aid

Section

Person Responsible for Account

Section

Responsible Party Physical Address
Responsible Party Physical Address
City
State/Province
Zip/Postal
Country

Next of Kin

Consent for Personal Information

By signing this document, you (the patient / client) agree(s) to the use of your personal information as required under the Protection of Personal Information Act, 2013. You also consent to the sharing of your personal information with third parties such as other medical professionals for purposes of rendering treatment to you and, where applicable, with medical schemes for billing purposes.