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To minimise paperwork on the day of your consultation, you are welcome to complete the below registration form. This will ensure that there is no delay in attending to your problem or medical condition. Please note that this is not a booking service. To make an appointment, please contact the rooms to find an available appointment slot. After making your appointment, you can complete the form below. The information will be submitted to the rooms to assist in opening your file.

Section 1: Patient Details


Please complete this section even if you only have a Hospital Plan

If NO, please complete section 3. If YES, proceed to section 4.



If applicable


General Terms and Conditions for Patients Joining The Practice

Dear Valued Patient

This document explains the general conditions under which this practice sees patients. It does not constitute an informed consent to any specific treatment. Informed consent will be provided each time you visit the practice, and will depend on the care you need/seek, and other factors such as your medical scheme cover.


You are obliged to provide your informed consent for any medical investigation, treatment or procedure to be performed by the doctor. Your rights obligate the practice to discuss the clinical aspects, financial implications pertaining to your health status, the diagnostic process as well as the different treatment options available. You have the right to retract your informed consent at any stage or to refuse such medical care. Should your treatment include admission to a healthcare facility where other healthcare specialists (like anaesthesiologists, physiotherapists, etc.) also become involved in your care and management, you are required to provide informed consent to their respective treatment and professional fee policies.

Under the provisions of The Children's Act, children may consent to certain medical treatment from the age of 12 years. Parents/ guardians are however required by law to cover the expenses incurred for the healthcare of their children. Doctors are obliged to guard the healthcare information of these children and to keep it confidential and only divulge the information subject to the child's consent. Please request the practice management staff to provide examples of these conditions, should you require further information.


In the current medical aid market environment, patients are purchasing lower cost medical aid plans with restrictive limits on treatment with less benefits, medicine restrictions, limited hospitalization and surgery cover, public hospitals as providers of pre-determined treatment and surgical procedures, and restrictions on access to doctors.

Your treatment, financial costs, and quality of your professional care can be severely affected by the type of medical plan you belong to and the generalization of statements such as "100% cover" by your medical aid or may not correspond with all the aspects of treatment you may require. These limitations often prove problematic for your doctor as the right to obtain the necessary professional medical care that meets an acceptable standard is being influenced by your choice of medical aid cover.
It remains your primary responsibility to familiarize yourself with the benefits and conditions of your medical aid plan. It is important that you know your benefit status with regard to the extent of your health cover, referral restrictions, savings account balances, registration and pre­ authorization processes, waiting periods and other requirements. The Medical Schemes Act 131 of 1998 and its regulations entitle members of a medical scheme to all information on their benefits and limitations of their plan. You are responsible to acquaint yourself with the benefits, insured rates and terms and conditions of your medical scheme plan.

Ascertain the exact amounts your scheme provides for in terms of consultations, procedures, assistants as well as what your medical aid will pay and not pay for.

Where a Designated Service Provider has been appointed by your medical aid, it remains your responsibility to be cognizant of this and to bear responsibility for any restrictions that may follow (either medically or financially) when consulting a non-designated doctor or facility.

With ever increasing intervention from your medical scheme, please be aware that this practice will not allow a medical scheme to violate the doctor's professional and clinical independence.
Where a medical aid or its advisors intervene to overrule your doctors preferred diagnostic approach or treatment, your doctor assumes no responsibility for consequent adverse outcomes. You may be asked to assume responsibility to the medical aid and its medical advisors in the event of complications.


In the event that hospitalization is required, it remains your responsibility to ensure that the planned treatment is covered by your medical aid and that the necessary finances are put in place to cover the non-insured costs. If pre-authorization is a required for any intervention, it also remains your responsibility to furnish the practice with the relevant information and authorization numbers. The practice may assist you in this process dependent on the individual practice policy. Where your medical aid questions the appropriateness of your treatment, your doctor may submit a letter of motivation to the medical scheme if appropriate and may also insist on a peer-to-peer discussion in above instances.


To avoid misunderstanding regarding payment policies and to maintain the professional healthcare standards of this practice, you will be informed of the current payment options and policies available in the practice. Please enquire from our front desk.
These fees are determined based upon the appropriateness of the quality and standard of services rendered. No accounts will be rendered for services not delivered or delivered to someone else.
This practice reserves the right to claim directly from you in which case you will be provided with a detailed invoice that is payable to the practice within 30 days from date of service. You have the prerogative to claim this back from your medical aid. This practice submits accounts subject to the National Credit Act, The Consumer Protection Act, the Medical Schemes Act and the guidelines as published by the HPCSA.

This practice reserves the right to charge a service fee for any credit given in terms of the provisions of the National Credit Act, Act No. 34 of 2005. In terms of section 101 (1) (c), an initial per transaction service fee may be charged on the transactions for which a credit amount is provided and thereafter on a monthly basis for each month a credit balance remains. In terms of section 101(1) (d), interest may be charged on the account for each month the credit amount is not paid by you. Where legal action is instigated for the recuperation of costs for services rendered or goods provided in terms and associated with the rendered service by this practice then in terms of section 101 (1) (g) collection costs may be imposed to the extent permitted by Part C of Chapter 6 of the National Credit Act, Act no 34 of 2005.

You will be informed of the practice billing policy and the prices for services generally rendered by the practice. Where an exact price cannot be presented, a quotation aligned with these applicable laws will be provided, subject to its own terms and conditions. This will be discussed with you at every visit or treatment event to the practice. Due to the billing policy of the practice and the fee your medical aid is reimbursing at, a co-payment may have to be levied by the medical aid or the practice.

You (or your parent/guardian) remain at all times liable for the account for services rendered by this practice even if you are insured by a medical aid or other third party. This agreement does not preclude the practice from taking all reasonable and practical steps to recover any outstanding amounts. The practice, as mentioned earlier, reserves the right to charge interest on your outstanding accounts due from date of service up to maximum interest allowed for in terms of section 2 of the Prescribed Rate of Interest Act.

It remains your responsibility to inform and update all personal and medical aid detail information with the practice and that you undertake to keep the practice regularly informed with regards with any changes on your contact details, benefits and list of dependents. Please note that the use of someone else's medical aid card with or without such a person's consent or knowledge constitutes fraud. This practice will report such instances to the medical aid concerned to protect the practice from being regarded as a cooperative in the fraud.


The Medicines Act 101 of 1965 determines that a pharmacist may substitute a product that appears on a prescription with a generic equivalent provided that the substitution contains exactly the same amount of active substances taken in the same dosage and taken via the same route. No prescription may be substituted where the doctor indicates "no generic substitution" on your prescription. This law does not allow for the therapeutic switches i.e. medicine in which the substances are not equivalent as described above although it may have the same or similar effect.

The Medicines Control Council (MCC) has issues guidelines on circumstances under which substitution is not allowed. Should you have any queries in this regard, please do not hesitate to contact the doctor. Should a substitution takes place at pharmacy level, you are entitled to enquire as to the nature of such substitution (generic or therapeutic) and may request that your prescribing doctor be contacted so as to enquire whether it would be in order to substitute the prescribed medicine.

Should you experience any side effects of any nature, please contact the doctor immediately and bring along with package(s) and the medication(s) that you have been taking. Bear in mind that various medicine may interact with each other and you have the responsibility to inform the doctor of all the medication you are taking at each consultation or visit.


All information handled by this practice is regarded and treated as strictly confidential by the doctor and the practice staff. Should you belong to a medical aid and the medical aid forwards such an account tot the principle member of the medical aid, confidentiality may be compromised as legislation compels this practice to provide certain information to the medical aid on the accounts. Failure to submit the correct codes might lead to claim incorrect being paid or not paid at all. Regulation 5(f) of the Medical Schemes Act (published in the Government Gazette No 20556 on October 20th, 1999) states that an account to a medical aid must contain the relevant diagnosis.

This must be submitted as an ICD-10 diagnostic code. It has become necessary to disclose these ICD-10 codes on prescriptions, referral letters, requests for special investigations (radiology, pathology, etc.)
In the event that a practice or its administrator approaches this practice with a request for confidential information and uncertainty exists over the soundness of the required confidentiality processes that has to be in place, the doctor will insist to follow the standard operating procedures as legislated in the Access to Information Act and its equivalent Acts or rules.

Your de-identified information may be used for epidemiological, research or practice business planning and may be passed on in a de-identified format to 3rd parties for further processing. For accurate health care planning, it is important that as much as required information is included in these types of analyses and that your participation in this regard is highly appreciated.


Certain medical conditions have been legislated by government as Prescribed Minimum Benefit Conditions that require your Medical Aid to pay out in full all Medical fees, which are usually above medical aid rates. This is independent of your medical aid plan. If your condition is a Prescribed Minimum Benefit Condition, in order to avoid any co-payments from your side, I would strongly advise that you contact your Medical Aid and inform them of the fact that you have a PMB Condition for which they should reimburse all Professional Service Providers involved in full.

Most PMB Conditions in urology, are normally associated with kidney stones, infections, cancers and some congenital conditions are also included. This legislation was designed to protect the consumer from out pocket expenses when subjected to unforeseen medical problems.

Payment in full for these PMB Conditions is dependent on certain criteria. Registration of the PMB condition is usually required.

The relevant ICD-10 diagnostic codes will be found on your statement together with the usual letter which we send to the Medical Aid informing them of the fact that your condition is a PMB condition and attached to this is the relevant PMB code which they will usually require.

My fees remain, as per legislation, the standard practice rate which is charged for all conditions, whether they fit in with the PMB codes or not.


Gap cover does not form part of your medical scheme membership. While your medical scheme is regulated by the Council for Medical Schemes, and the Medical Schemes Act, Gap cover falls under the Short-term Insurance Act. GAP cover is provided by short term insurance companies. Please refer to your broker for more information.

GAP cover is often used to reduce the co-payments for specialist- and hospital fees.


I hereby acknowledge that I have read and understood the above information prior to having signed, and that all information submitted by me is true and correct. I understand that I am under a continuing obligation to advise this practice/ practitioner of any changes that may occur after submission of this contract and acknowledge, by signing this contract, that I am legally bound by the provisions of the contract. This contract is subject to the provisions of the National Credit Act and the HPCSA ethical rules. I understand that this contract constitutes part of terms and conditions under which professional services will be rendered, in compliance with the Consumer Protection Act. I understand the implication and agree to, where appropriate, the doctor and practice disclosing my ICD-10 diagnosis code(s) under the conditions described above.

+27 (012) 940 8278

Suite M31, Third Floor
Netcare Pretoria-East Hospital
C/O Garsfontein and Netcare Road
Moreletapark, Pretoria, 0181
South Africa

Practice Number: 0478563