012 942 9571 info@kidneyspes.co.za

Patient Registration Form

Patient Registration

Patient Details

Medical Aid Details

GAP Cover YesNo

General Practitioner

Person Responsible for Account

Next of Kin / Friend / Relative


I, the undersigned, am personally responsible for payment and not my medical aid. • In the event of divorce the parent accompanying the minor is responsible for settlement of the account. • In the event of any legal action being instituted against me for recovery of any amount whatsoever, I shall be liable for all legal costs including admin costs and a 20% admin fee on each instalment paid. If the matter is defended, I will be liable for legal costs incurred on an attorney/client scale. • Once my account has been handed over there will be no further correspondence entered into with the practice. All correspondence will be with Absolute Debt Solutions or LEXMED. • The National Credit Act 34 of 2005 is not applicable to this claim. I hereby choose my above address as my domicilium citandi et executandi for all purposes under this agreement.

I have read, understand and agree to the conditions mentioned above. I confirm that the information provided by me is true and correct. By signing this document, I legally bind myself to the terms and conditions contained on the back of this page and confirm that I read and understood the information contained therein.

I Agree