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admin mobile

New Logo 2019 Mobile

Person responsible for account:

  

Employer:

Dependants:


We are not contracted in with any medical aid. Patients to pay doctor first and claim from medical aid there after. All accounts must be settled  within 7 days from service date.
New patients must settle on the day of consultation.

Medical Aid Details

Nearest Relative / Friend not living with you

How would you like to receive your account?

Important: You are still responsible for settling your account even when you change your address, email or telephone number.
Please let us know Immediately of any changes.
I agree that all the above patients' diagnosis or reasons for consultation will be made available in ICD10 code form on my statement, as required by medical aids and health authorities.
I accept that interest will be charged on all accounts older than 30 days, and in event of any legal/collection costs incurred to recover any monies outstanding, I undertake that the costs will be paid in full by myself.
I accept the terms and conditions as set out above by the pracrice of Drs GA Haasbroek, FH van Wijk, PdeV Odendaal & M de Wet practice no. 1577123.
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