Referring Dr & Tel No.
Medical Aid Name
Medical Aid Option
Medical Aid No
M/m Dep code
Relationship to patient
Name & Surname*
Relationship to patient*
I hereby certify the above is true and correct. All consultation fees are payable on the day of the consultation. Dr Naidoo enters into an agreement with you and not your medical aid. It is the members’ responsibility to inform the accounts department of any changes in personal details. I understand that should my medical aid not pay claims, it will be my responsibility to pay Dr Naidoo and claim back from the medical aid. Outstanding accounts must be settled strictly within 14 days. All overdue accounts exceeding 14 days will be listed on ITC and handed over to the attorney. A charge will be added on all overdue accounts. Should your account be handed over for collection, you will be liable for all legal costs on attorney and client scale, collection charges and tracing fees, as well as VAT where applicable. I hereby choose the given address as my domicilium citandi et executandi address. Please note private fees are billed.
To download a document about patient fees, please click here
SIGNATURE (Below)(Person responsible for payment)
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