PATIENT INFO
New Patient Form
TERMS AND CONDITIONS
1. THE PRACTICE– The medical/dental practice as attended by the patient (Hayes Dental, PN 0627852, 9BTyger Manor Centre, c/o Willie Van Schoor & Bill Bezuidenhout).
2. ACCEPTANCE– The undersigned patient, responsible person, parent or legal guardian, hereby assumes liability as the principle debtor, alternatively as the co-debtor jointly and severally with the patient for the payment of any claims by the practice arising from any medication given or services rendered to the patient, notwithstanding the existence of a medical aid fund or insurance covering such claims.
3. TERMS OF PAYMENT– Any person who signs this document in any of the capacities described above, confirms that he/she (1) has ascertained him/herself of the tariffs charged by THE PRACTICE, (2) is familiar with his/her medical aid guidelines, stipulations, and requirements before starting with treatment. (3) As PRIVATE PATIENT will settle the account immediately after consultation. (4) Will settle the account within 30 days if despite of the reason, it was not paid by the medical aid. (5) Will settle all LAB fees before the final appointment, and that he/she will claim it from the medical aid. (6) THE PRACTICE is not liable for the submittance of medical claims with any medical fund.
4. BREACH– In the event where any of the abovementioned parties commits a breach of contract, THE PRACTICE is entitled to take immediate legal action and charge arrears interest at a rate of 15% per year on the outstanding balance from the date of invoice to the date of payment.
5. GENERAL– This Form of Admission constitutes the whole and entire agreement between the parties and there have not been and there are no agreements, representations or warranties between the parties other than those specifically set forth herein. No variation, modification or cancellation of this agreement shall be any legal force or effect unless the same shall be confirmed in writing and signed by all parties involved.
6. JURISDICTION– This agreement is subject to and shall be interpreted and construed in terms of the laws of the Republic of South Africa and is subject to the jurisdiction of a competent court in the Republic of South Africa.
7. PERSONAL INFORMATION– The undersigned, patient, responsible person, legal guardian, or surety of the patient hereby authorizes THE PRACTICE to collect, share and exchange credit information concerning them with any credit bureau or any other person or corporation with whom they may have had or may have financial dealings, as well, where applicable, other information requested pursuant to, or in any circumstances contemplated in the National Credit Act, act 34 of 2005. Furthermore, THE PRACTICE is given the right to disclose personal medical information such as ICD10 diagnostic codes and clinical information pertaining to the patient to it’s legal representative, debt collectors, health care providers, medical schemes, administrators & service providers provided that such information is treated as confidential and in good faith only insofar as it is necessary for debt collecting purposes.
8. DOMOCILIUM– The parties choose the domociliumcitandi et executandi at the address shown overleaf.
9. LEGAL COSTS– Should THE PRACTICE commence legal proceedings, the patient undertakes to pay all legal costs relating to the recovery of the outstanding monies in respect of professional services rendered, including attorney fees on an attorney – own – client scale, collection fees and commission, interest and tracing costs.
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