CONSULTATION FORM

Consultation Form

Patient Details:


Principle Member Details:


Next of Kin Details: (Not the same as above)


Referred by:


Medical Aid Details:


INFORMATION REGARDING CONSULTATIONS

  • All consultations: As per your medical aid rate or R1240.60 (Standard Discovery rate) for private patients.
  • 90min couples Session: R2000 investment.
  • Certain medical aid schemes do not cover psychological consultations. It is therefore the responsibility of the client to settle all outstanding accounts.
  • Appointments not cancelled 24 hours before the appointed time will be charged to your account.
  • Accounts are payable 30 days net.
  • The undersigned shall be liable for any legal proceedings instituted for the recovery of any overdue payments, including all legal charges on the scale as between attorney & his client.
  • Consent is hereby given to this practice to allocate an ICD-10 diagnosis on the client’s account as required by medical aids from 1 January 2006.
  • NOTE: This information will be shared with a medical billing bureau called Data Spot-On where your information will securely stored in line with South African POPI act. This is for billing purposes only and won't be shared or used for any other purpose.