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Patient Form


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Same as Residential Address ?
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Me Someone else
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Please communicate to your physiotherapist regarding your condition or treatment before, during or after the day of treatment!

Please do not tolerate excessive pain/ heat/ discomfort during your treatment without mentioning it to your physiotherapist.

It remains the patient’s and/ or guardian’s (in case of a minor) responsibility to settle all the outstanding amounts for physiotherapy, regardless of whether a claim was sent to your medical aid or not. If your medical aid does not settle in full, the outstanding amount is still for immediate settlement by yourself. It is your responsibility to check what your medical aid and plan would cover in terms of physiotherapy and what not. It is the patient’s / guardian’s responsibility to send a claim through to your medical aid should you want to be refunded by your medical aid.

Please settle immediately after the treatment, ideally via EFT (an electronic bank transfer) /on the same day of receiving the invoice, directly to this practice. Banking details are available on request.

This practice has credit/debit card facilities for all the major credit cards only.

I undertake to pay all fees related to my physiotherapy treatment immediately after receiving an invoice and I am aware that failure to settle immediately could result in interest being incurred at a rate of prime plus 3%. I undertake to pay all legal fees for debt collecting should I not settle timeously i.e. within 30 days of treatment. Legal fees will be charged at an attorney to client’s scale as determined by a private attorney in the unfortunate event of the patient or person responsible for the account failing to fulfil their financial obligations with regards to their physiotherapy treatment with this practise.

MAP & DIRECTIONS

address Unit 105 A, Medical Suites, Office Top Floor, Corner of 95 Bram Fischer Drive & George Avenue, Ferndale, Randburg.

Location directions:
Take Republic off William Nicol Road, turn left in Bram Fisher drive, turn right into George street (3rd road on right) and Bram Fischer Complex is immediately on your left. Park anywhere and use lift or stairs to Office floor. Stairs are behind the cell phone shop on the shop floor.

Take Boundary Road off Malibongwe Drive. Turn left into Bram Fischer drive, turn left into the Bram Fischer Complex just after you pass the intersection at Will Scarlet Road, second shopping centre on your left just before George Road. Park anywhere, use lift or stairs behind the cell phone shop. Medical Suites are on the office floor.

CONTACT DETAILS

telephoneRandburg : 082 608 0474

emailpalmus@netactive.co.za