Dr Linda van Deventer

Title:

Full names:

Surname:

ID no:

Date of birth:

Cellphone number:

Email address:

Please confirm EMAIL address:

Physical home address:

Postal address (if different from above):

Work address:

Employer:

Work phone number / land line number:

Details of Person responsible for account / Medical Aid main member (Name, Surname, ID, Phone number, Email address, Physical address):

Next of Kin (Name and Phone number):

Medical Aid:

Medical Aid option/plan:

Medical Aid number:

Medical aid dependent code/number for patient (if applicable, only certain medical aids):

I, the patient, or legal guardian, accept all the terms and conditions of the practice (available at our office and on request) and I take full responsibility for my account and I do understand that I am liable for the full account on the day of service and will be billed for missed appointments not cancelled at least 24 hours before my appointment in writing (info@skindr.co.za):

Yes
No

I do understand that the doctor unfortunately cannot respond to the many email / telephone communications and that all email/telephone communication that require a response from the doctor might incur a consultation cost:

Yes
No

Additional information (optional):

User Agreement

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