New Patient Details

I, the patient am authorised as a registered dependant of the main principal. In case of a medical claim, the responsibility for payment of this account rests with the principal member of the medical aid.

The above residential address is the domicilium et citandi et executandi for all purposes of this agreement by law. I declare that above-mentioned is responsible for payment of the patients account. Any changes of address will immediately be reported to this practice. I undertake to pay any legal costs in order to recover outstanding debts. I agree to pay interest cost should I not settle this account timeously with the doctor.