Forms Patient Contract Download Form Here MAIN MEMBER OF MEDICAL AID / PERSON LIABLE FOR ACCOUNT Surname Title Initials Full names ID No Email address Cell phone No Postal address Postal code Home address Postal code [address chosen as my domiculium citandi et executandi where all legal notices pertaining to my account can be served on me] Occupation Tel (W) Employer Work address PATIENT INFORMATION: Surname Title Initials Full names ID No Email address Date of Birth Cell phone Tel (H) Tel (W) Referring Dr Next of kin not living with you: Initials and Surname Cell phone No MEDICAL AID INFORMATION: Medical Aid Med Aid Option Membership No Dependant Code of Patient Authorization No Accept Terms and conditions and privacy notice. Submit Pasient Kontrak Download Form Here HOOFLID VAN MEDIESE FONDS /REKENINGPLIGTIGE Van Titel Voorletters Volle name ID No Eposadres Selfoon No Posadres Poskode Huisadres Poskode [adres word aangewys as my domicilium citandi et executandi, synde die adres waar alle regskennisgewings wat op my rekening betrekking het, beteken kan word] Beroep Tel (W) Werkgewer Werksadres PASIëNTINLIGTING: Van Titel Voorletters Volle name ID No Eposadres Geboortedatum Selfoon No Tel (H) Tel (W) Verwysende Dr Naasbestaande wat nie by u woonagtig is nie: Voorletters en Van Selfoon No MEDIESE FONDS INLIGTING: Mediese fonds Fondsopsie Lidnommer Afhanklikheidskode van pasiënt Magtigingsnommer Hierdie onderteken en ooreengekom te op Handtekening Accept Terms and conditions and privacy notice. Send Authorization for Procedures Download Form Here Authorization for Procedures (Afrikaans) Download Form Here Cureday Pre Admission Form Download Form Here Netcate Pre Admission Form Download Form Here Contact Us Name Email Address Message . . Accept Terms and Conditions and Privacy Notice 1 + 6 = Submit Dr Hendrik P Ehlers Reception Charmian Lamprecht 012 998 9133 064 680 1507 reception@drhpehlers.co.za Accounts Coleen Harmse 012 998 9133 064 680 1507 accounts@drhpehlers.co.za Theatre Bookings Colette Lippold 012 998 9133 064 680 1507 theatre@drhpehlers.co.za
