Medical Aid, Main Member and Patient information form. Please fill in all required fields.
Main Member Information
Medical Aid (If Applicable)
Patient Information (Please fill ALL fields if different from main member)
Next Of Kin (Not living at the same physical address)
Hereby I confirm that the information I supplied is true and I am responsible for any false information provided. All fields with * are mandatory. I take full responsibility for the account for services rendered by this practice, even if I am insured by a medical aid or other third party. I take note of the fact that, in the event of non-payment within 90 days, my name will be listed on “ITC”, a national data base of slow payers. By accepting these terms and conditions you agree to our Protection of Personal Information Act (POPIA). Here at Dr Ackermann's practice, we take our client's privacy seriously and we would like to ensure that we have your consent to keep sending email communications to you. If you are happy to stay on our mailing list to receive our special offers and announcements, no action is required. Should you no longer wish to be part of our mailing list, contact us directly to be unsubscribed.
Thank you for your continued support!