PAYMENT AGREEMENT, DECLARATION

and CONSENT TO TREATMENT

My signature below constitutes my aknowledgement and acceptance that I,
Mr/Ms ________________________________________________________________, Id.no.

as patient, parent, spouse, legal guardian, person having custody of mentioned minors, hereby
1.

Agree to adhere to the following payment regulations:

I, in person, am fully responsible for all accounts charged, not a medical aid fund.
I undertake to settle the charged amount, as mentioned beforehand, myself in CASH during the visit, or
if the supplier claims the mentioned amount, on my behalf, from my Medical Aid Insurance, I undertake to
pay the requested administration fees before the consultation, and will see to it that the account is paid in
full within 14 days.
I undertake to verify accounts and inform the supplier within 7 days of any errors.
I undertake to supply within 14 days any changes in address, phone numbers or medical aid information. I
understand that, if I fail or neglect to keep my responsiblities according to this account, legal action can be
taken against me in order to demand settlement thereof, and confidential information will be supplied to the
Debt Collectors.

2.

I am aware that the following are not included in a consultation fee and are additionally
CHARGEABLE:
*
*
*
*
*
*
*

Telephonic services, like consultations or requests for scripts.

Phone calls in connection with patients to medical aids or specialists.
Faxing or mailing of scripts, forms, letters and accounts.
Compiling of letters or completion of medical reports and forms.
Injections, syringes, gauze, needles, gloves and other consumables during procedures.
Submitting of accounts on behalf of members to medical aids.
Procedures eg. ECG, Lung Function, BMI, Suturing, Excision of lesions etc.

3.

I am aware of the current Tariffs and Levies payable, for each patient, with every visit.

4.

I declare that all information and the address as domicilium citandi et executandi provided,
is just and correct.

5.

I agree to and grant my voluntary consent to all treatments, injections, operations, minor procedures and
professional services upon myself or my dependants, requested on my own insistence, by Dr. D.D.R. van
Tonder, General Practitioner, trading as such at 7 Deeks Avenue, The Orchards x13, AKASIA.

6.

I agree to grant consent to any radiological or other examinations, taking of blood or urine samples,
laboratory tests, pshysiotherapy and hospital or clinic services that the said doctor may prescribe, only
when information to my satisfaction has been supplied.

7.

I declare that I am not under administration order, sequestration or debt counselling in

terms of the National Credit Act. (Such a person may not acquire credit, and must pay cash for services)

8.

I hereby certify that I have read this document, understand the contents thereof, and received a copy of
it.
Signed on _______/______ / 20 ______ at AKASIA, Pretoria, Gauteng.
________________________________
Patient / Spouse / Parent / Guardian

____________________
Credit Control