Post Natal Preparation Course
FAMMED CLINIC
Sr Kitty Nortje
PR NO 8818126
Cell: 082 892 7686
Address: 14 Sterretjie Avenue
Rooihuiskraal
CENTURION
Tel: (012) 661 6286
Fax: (012) 661 4476
Fax to Email: 086 541 2892

Details of Patient

Name:
  *
Surname:
  *
First Name:
Gender:
Tel (h):
  *
Date of birth:
Language preferred:
Number of children in family?:
Date of Consultation:

Details of Person Responsible for Account

Title:
Initials:
ID No:
Employer:
Occupation:
Telephone work:
E-mail address:
Postal Address:
Home Address:
Medical aid:
Medical Aid Number:
I personally undertake full responsibility for payment of this, and future accounts, even in the event that the medical aid does not, for any reason whatsoever, pay the account I accept all recovery and legal costs if the account is not fully paid within 120 days. I undertake to inform you immediately of any change of address or medical aid. Interest will be charged at bankrates on all outstanding amounts after 90 days.
Agreement:
I agree (Person responsible for account)
I agree (On behalf of person responsible for account )
Relationship:
Dependant Name:
Dependant Address:
Dependant Telephone Nr:
Send me a copy
* Required field