Patient Information Form Patient Details First Name Surname Date Of Birth ID / Passport Number Postal Address with Postal Code Home Number Cell Number Email Address Work Number Contact Referring Practitioner Physiotherapist Neurologist Occupational Therapist Orthopaedic Surgeon Other Person or Medical Scheme Responsible for the Account First Name Surname Select Your Title Select Your Title *MrMrsMissDrProfRevOtherNone ID Number Email Address Date Of Birth Postal Address with Postal Code Home Address with Postal Code Employers Name Employer's Tel Cell Number Home Number Work Number Medical Aid Plan M/A Number Next of KIN/FRIEND Not living with you Select Their Title Select Their Title *MrMrsMissDrProfRevOtherNone Full Name Relationship to Patient Cell Number Email Address View our Terms and Conditions here and accept them by clicking the block below Terms and Conditions Terms and Conditions I have read and accept the Terms and Conditions Please indicate your preferences regarding information sharing Please tick the appropriate box/boxes Please tick the appropriate box/boxes I consent to information about my child being shared with other healthcare professionals involved in their care I consent to information about my child being shared with their schoolteacher or school-based support staff I consent to billing and account information being discussed with other healthcare professionals involved in my child's care I consent to claims being submitted to my medical aid on my behalf by Yovanka Torrente & Associates We are committed to providing a safe and respectful environment for both clients and staff. Any form of abuse towards staff members, including but not limited to verbal harassment, physical intimidation, threats, or inappropriate communication, will not be tolerated.If such behavior occurs, we reserve the right to terminate services immediately and, if necessary, involve appropriate authorities. By signing this form, you acknowledge and agree to always treat all staff members with respect. Please indicate your preferences regarding information sharing Client_signature_(Parent_or_Guardian) SaveClear Print Name New Field To ensure that appointments are available for all patients, we kindly request at least 24 hours' notice for any appointment cancellations or rescheduling.Appointments cancelled with less than 24 hours' notice or missed without prior notification ("no-shows"), may be subject to a cancellation fee.Custom-made devices or orders that have already been manufactured, ordered, or commenced cannot be cancelled and remain payable in full.We appreciate your understanding and cooperation, as this policy allows us to provide the highest standard of care to all our patients.All accounts that are not settled by the medical aid and are made patient liable are to be settled, in full, immediately on receipt of said account. Submit Form
