Dear Patient, We would like to welcome you to our practice. It is our privilege to be able to assist you with your or your family’s skin problems. In order to streamline administrative matters, please note the following: PROCEDURES: 1. During a consultation it often transpires that a procedure is required to be performed. Only if the time booked for the consultation allows it, will the required procedure be performed at the same time. In the case of longer or multiple procedures a separate and specific appointment is booked for this purpose. 2. The cost of performing procedures, as well as the use of the Fotofinder mole evaluation equipment, is excluded from the consultation fee. TARIFFS: 1. Tariffs are contracted out of the guideline used by medical aids. 2. Patients should settle their account in full after the consultation unless a specific arrangement is made.An invoice and receipt will be given to you, and you will be able to submit the account to your medical aid. 3. A list of tariffs is available at reception if you are interested. Should you require, you can also ask for an estimated cost before any service or procedure is performed. As an example, for a typical procedure, you will be liable for approximately 25% of the procedure cost. The medical aid should cover the rest. 4. The recommended tariffs will be levied for all telephonic consultations, repeat prescriptions, letters of motivation, as well as completion of chronic and insurance forms. 5. Please cancel appointments in time to allow for scheduling of another patient into that time slot. In the case of a patient not arriving for a scheduled appointment, the patient will be held liable for the consultation fee. This is standard practice as published in the Government Gazette and supported by the South African Medical Association. 6. Outstanding accounts not settled within a reasonable time are handed over to a debt collection agency.PATIENT PARTICULARS / PASIëNT BESONDERHEDESurname / VanTitleNames / NameNickname / NoemnaamID/Passport nr / ID/Paspoort Nr0 / 10000000000000Date of Birth / GeboortedatumHome Address / HuisadresPostal Address / PosadresPostal Code / PoskodeWork Tel / Werk Tel0 / 100Home Tel / Huis Tel0 / 100Fax / Faks0 / 100Cell Phone / SelnommerEmail AddressOccupation / BeroepEmployer / WerkgewerReferred by / Verwys deurGeneral Practitioner / HuisdokterTel nr0 / 100Tel nr0 / 100Allergies / AllergieëMain Member of Medical Aid/Person responsible for payment of account / Hooflid van Mediese Fonds/Persoon verantwoordelik vir betaling van rekeningTitle / TitelNaam / VoornaamSurname / VanID Nr / Passport NrDate of Birth / GeboortedatumPostal Address / Posadres0 / 100Postal Code / PoskodeWork Tel / Werk Tel0 / 100Home Tel / Huis Tel0 / 100Fax / Faks0 / 100Cell Phone / SelnommerEmail AddressEmployer / WerkgewerMedical Aid / Mediese FondsMediacal Fund Name / Mediese Fonds NaamPlan0 / 100Medical Aid Nr / Mediese Fonds NrNearest family, friend details / Naastebstaande besonderdePatients on same Medical Aid / Pasiënte op dieselfde Mediese FondsTitle / TitelFull Names / Volle NameNickname / NoemnaamAllergies / AllergieëDate of Birth / GeboortedatumMale or female / Manlik of vroulik0 / 100 Please direct any grievances or complaints to the practice in writing. Section 14 expressly provides that no one is entitled to disclose any information pertaining to a health user’s health status, treatment or stay in a hospital unless the user has consented thereto in writing. The only circumstances where a practitioner may disclose without consent is where required to do so by law (such is in the case of communicable diseases), or in terms of a court order or where non-disclosure would pose a serious threat to public health. Section 15 permits the flow of information necessary in rendering healthcare services to patients, provided it is for a legitimate purpose within the ordinary course of a health professional’s duties and the disclosure is in the interests of the user. Section 17 obligates persons in charge of health establishments to set up control measures to prevent unauthorised access to health records and storage systems the patient/guardian herewith grant permission for my personal information to be captured on Elixir for the practice of Dr. Ugeshnie Naidoo and used for communication purposes between the practice and you, the patient. Your information will not be shared with any third party, other than a medical institution that you might be referred to by Dr. Naidoo. For Example: Pathologists, Radiologists, Oncologists, Surgeons, etc.Yes, I agree with the privacy policy and terms and conditions. Yes, My information is correct. Send Message