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1. PATIENT DETAILS - SECTION 1
Surname *
Full name *
Title *
Initials *
Known As *
Gender *
Date of Birth *
ID Number *
Marital Status *
Home Language *
Allergies *
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2. PATIENT DETAILS - SECTION 2
Residential Address *
Code *
Postal Address *
Code *
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3. MEDICAL SCHEME DETAILS
Full name *
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Main Member Full name *
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4. DEPENDANTS - PLEASE COMPLETE AS PER MEDICAL SCHEME CARD
Code
Name & Surname
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Contact Number
ID Number or Date of Birth
Allergies
Code
Name & Surname
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Gender
Contact Number
ID Number or Date of Birth
Allergies
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5. NEXT-OF-KIN IN CASE OF EMERGENCY
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Office Number *
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6. PERSON RESPONSIBLE FOR ACCOUNT PAYMENT
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Pay Us A Visit

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012 362 2799

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012 362 2790

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docma18@gmail.com

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4th Floor Hatfield Plaza
1122 Burnett Street
Pretoria

Monday:

08:30 - 19:00

Tuesday:

08:30 - 19:00

Wednesday:

08:30 - 17:00

Thursday:

08:30 - 17:00

Friday:

08:30 - 12:00, 14:00 - 17:00

Saturday:

09:00 - 13:00

Sunday:

Closed