Patient Information Form Title Dr Mr Mrs Ms Miss Name Surname Initials Date of Birth ID Number Residential Address Postal Address Occupation Employer Tel No (Home) Tel No (Work) Mobile No Email Full Name Relationship Mobile Number Address Title Dr Mr Mrs Ms Miss Name Surname Initials Date of Birth ID Number Mobile No Tel No (H) Tel No (W) Email Name of Medical Aid Medical Aid No. Plan/Option Principle Member How did you hear of Suede Wellness? InternetEmailWhatsappFacebookFriend/Family ReferralOther If Other, please specify How would you like to be reminded of your appointment? Call SMS Email I hereby agree and consent to disclose all relevant information regarding my medical condition, and allow consent to a Physical Examination and Treatment, including dry needling, IV, oral and fitness treatment by the relevant practitioner. It is important to note that whilst the treating practitioner keeps your diagnosis confidential, your ICD 10 code for the diagnosis will appear on the statement of account, as it is a requirement for billing purposes to the medical aid. I hereby assign to SuedeWellness Life Resilience Institute/PhysioWellness all money to which I am entitled for medical expenses relative to the services provided. If benefits are not assignable, I agree to pay for these within 30 days of receipt of the settlement proceeds of the liability claim. I agree that I am financially responsible for charges not covered by my insurance company. We reserve the right to charge R400 for missed appointments or appointments not cancelled 12 hours prior to the stipulated time. Send
