Hout Bay Family Medical Centre

Please Check The Box If You Would You Like To Receive Our Monthly Newsletter

PERSONAL

Title *

First Name *

Surname *

Date Of Birth *

ID No. *

Postal Address *

DEPENDANTS (Full names, Date of Birth, ID No.)

Dependant 1

Dependant 2

Dependant 3

Dependant 4

Residential Address *

MEDICAL AID

Medical Aid

Plan / Option

Medical Aid Number

PERSON RESPONSIBLE FOR THE ACCOUNT

First Name *

Surname *

Phone / Mobile *

ID No. *

I confirm that the above information is both true and correct. I agree and understand that I will be liable for any legal costs incurred in the recovery of outstanding fees. *

I have read and understood the Privacy Policy & POPIA section on this website and consent to Hout Bay Family Medical Clinic processing the information submitted in this form for healthcare and related administrative purposes. *

PLEASE NOTE:
Private patients please settle account after consultation. Medical Aid patiEnts will be held liable for their
account should the claim be rejected due to no funds available and any shortfall. Kindly follow up on
non-payments from Medical Aid.