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PATIENT INFORMATION FORM

Fill in the fields below to submit and/or update personal information to Scholtz & Partners Radiology Inc

Full Name and Surname:

Date of Birth:

Patient ID number:

Address:

Medical Aid:

Medical Aid Plan:

Medical Aid Number:

Patient dependant code:

Main member Name and Surname:

Main Member ID number:

Email:

Phone:

Examination requested:

Referring clinician:

By completing this request, I hereby give Scholtz & Partners permission to use my information prior to my examination for administrative purposes:

Yes

By completing this request, I hereby give Scholtz & Partners permission to email all billing requests as well as imaging required:

Yes

By completing this request, I hereby acknowledge that I am responsible for all payments not made by my medical aid:

Yes