Patient Form

Patient Details



Date of Birth (mm/dd/yyyy)




Person Responsible for the Account





Postal Address:



Home Address:






Employment Details:





Family or Friends Details


Medical History:



















I Agree

I confirm that the above information is true and correct.
I undertake to inform you of any changes thereto within 14-days of changes occuring. Interest at prime +5% p.a. will be charged on all outstanding amount after 60 days. I accept full responsibility for any legal costs involved in collecting outstanding debts.


YOU AGREE THAT WE MAY:
Make enquiries to confirm any information provided by you. Seek any information from any credit bureau when assessing your application for credit, and at any time during continuing indebtedness to us, including tracing or confirming your whereabouts. Disclose the existence of your account to any credit bureau, sharing both positive and negative payment information about such account. Furthermore, you agree that we will be entitles to obtain and disclose the above information – if we consider that it is necessary or may be of benefit to you – where we are under legal obligation to do so – where it is in our own or the public’s interest that we do so.

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GIVE US A CALL

TO SCHEDULE AN APPOINTMENT.