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Patient Form


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Cell Home Work
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

address149 Oak Ave, Ferndale, Randburg 2194 View Map

addressWaverley Health & Wellness Centre, 17 Lennox street View Map

CONTACT DETAILS

telephoneRandburg : 011 886 0869

telephoneWaverly : 011 440 6411

telephoneBryanston: 011 704 1981

telephoneCell: 082 608 0474

emailpalmus@netactive.co.za