Patient Intake Form

Complete medical information

Saving draft...

Main Member Information

Medical aid holder details

ID Number *

Surname *

Full Names *

Initials

Gender *

Title

Date of Birth *

Home Language

Cell Number *

Work Number

Home Number

Fax Number

Email Address *

Email Statement

Postal Address *

Postal Code *

Physical Address *

Postal Code *

Medical Scheme *

Plan/Option *

Member Number *

Main Member Dep Code

GAP Cover

Patient Information

Patient/dependent details

ID Number *

Surname *

Full Names *

Nick Name

Cell Number (for appointments) *

Occupation

Marital Status

Age

Height (m)

Weight (kg)

Referring Doctor

Tel

Next of Kin

Emergency contact information

Full Names *

Cell Number *

Relationship to Patient *

Declaration & Signature

I confirm that the information I supplied is true and I am responsible for any false information provided.

Name in Print *

Date of Signature *

Signature *

Allow mass communication or notices from practice

All fields with * are mandatory. Please note that you (or your parent/guardian) remain liable for the account for services rendered by this practice, even if you are insured by a medical aid or other third party. Please ensure that you have read and signed the attached Doctor-Patient contract.