Dr James Beatty: Patient Information Form

Main Member Information

Date of Birth:

Medical Aid Information

Patient Information

Date of Birth:

Main member's Cell Phone number will be used if the above is No

Next of Kin: (Not from the same physical address)

Hereby I confirm that the information I supplied is true and I am responsible for any false information provided

Signature:

Clear

All fields with * are mandatory. Please note that you (or your parent/guardian) remain liable for the account for services rendered by this practice, even if you are insured by a medical aid or other third party. Please ensure that you have read and signed the attached Doctor-Patient contract.