1. I confirm that the information furnished by me above is true and correct.

2. I confirm that provided my doctor and I agree on the fees in advance, I remain personally responsible for the full fee should there be rejection or the unpaid balance should there be any short payment of my account by my medical scheme.

3. I confirm that I will pay interest on amounts outstanding for more than 30 days from the date of statement at today’s prime lending rate plus 2%.

4. I confirm that I am personally liable for the costs of the services delivered by my doctor to me or my family. The fact that I belong to a medical aid does not remove my ultimate responsibility to pay accounts from this practice.

5. Should legal costs be incurred by the practice as a result of my non-payment, I acknowledge that these are for my account, at an attorney-client rate

6. Popi compliance clause: I hereby consent to the processing of my personal information contemplated in the protection of personal information act no 4 of 2013, by Dr Jordaan. The practice staff and third parties with whom Dr Jordaan Has a contractual relationship for the following purposes:

   1. Treating and managing me in terms of a doctor-and-patient relationship;

   2. The administration of the contractual relationship between myself and Dr Jordaan

   3. Communicating with other persons in as much as it relates to my treatment and management;

   4. Communicating with third parties who have undertaken to indemnify me for the costs of my treatment and management or part thereof including medical schemes and their administrators where relevant; and

   5. Collecting monies outstanding from me.

7. My doctor may use any of the details provided on the forms either physical or electronic that I completed to pursue payment by me for unpaid accounts for whatever reason I also agree that in the event of non-payment, my name may be circulated on a limited medical blacklist.

8. I authorise my doctor to destroy records if they have been inactive for longer than 6 years. (adults) or in minors, after having reached 21 years of age and the patient file having been dormant for the preceding 6 years.

9. I authorise my doctor to provide my medical aid with my personal medical information to administer claims.

10. I consent to the occasional Email and SMS communications sent to me from this medical practice. Knowing that if I no longer want to receive this communication, I can opt-out of it by notifying the practise receptionist.

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