Make an appointment Download Registration "*" indicates required fields Are you a returning patient?*Current PatientNew PatientType of appointment*Virtual/Online AppointmentRegular AppointmentAny of the abovePatient DetailsFull Name* First Last SubjectTitle*Mr.Mrs.Ms.MissOtherDate of Birth* DD slash MM slash YYYY Occupation* ID no.* Home Language*EnglishAfrikaansSothoOtherMarital Status*MarriedDivorcedSingleWidowedOtherReligion Email* Tel(H): Tel(W): Cell:* Employer* Employer email* Person Responsible for Account(Please see practice terms and conditions)Full Name (Person Responsible)* First Last Title*Mr.Mrs.Ms.MissOtherDate of Birth* DD slash MM slash YYYY ID no.* Home address:* Street Address Address Line 2 City State / Province / Region Post address the same as home address?* Yes No Post address:* Street Address Address Line 2 City State / Province / Region Tel(H): Tel(W): Cell:* Person's Email* Are you currently under debt review and/or Administration Order issued by a competent Court for the management of your debts* Yes No Medical Aid DetailsDependant Code:* Medical Aid:* Plan/Option:* Number:* Main member:* Authorisation Tel no:* Main member ID:* Next of Kin Details(Partner/Parent/Sibling/Friend)Full Name (Next of Kin)* First Last Relationship* Tel(H):* Tel(W):* Cell:* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte 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IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Referring PractitionerFull Name (Next of Kin)* First Last Speciality:* Email Address:* Tel:* Cell:* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country DECLARATION* I, the undersigned, hereby testify all the above information to be accurate to the best of my knowledge and I accept all terms and conditions as specified in the provided practice documentation. PRACTICE TERMS AND CONDITIONS I agree to the practice terms and conditions.I, the undersigned, hereby acknowledge and accept the following practice regulations: As the self-declared person responsible for this account (irrespective of whether I am the main member of a dependant on a medical aid), I accept that I am solely responsible to settle this account irrespective of my agreement with my personal medical aid/insurance. I acknowledge that my medical aid membership is a personal agreement between the relevant scheme and myself and that if there is any delay or dispute regarding payment, I will settle the account personally within 30 days of services rendered. This practice reserves the right to claim directly from you, in which case you will be provided with a detailed invoice. This is payable to the practice upfront or within 3 days from date of service. If my account becomes overdue, I am aware that 5% interest will be charge per month and that legal steps may be taken with any additional costs incurred to be added to my account. I will notify the practice immediately, in writing, should any of my personal or medical aid information change. I have been informed that this practice charge private healthcare rates which is more than reference price listings utilised by the medical aid/insurance schemes. I realize that I will receive additional bills for any blood tests, pap smears, x-rays or procedures form the relevant laboratory or any other additional service provider. I have been informed that Prof Henn reserves the right to bill specialist rates for all email and telephonic consultations as well as motivation letters, repeat scripts and medical reports according to the practice’s billing policies and that he will not correspond on medical matters via sms/Whatsapp or similar platforms. Although Prof Henn will be mostly available for after-hours services or advice, I am aware that this practice can make use of locum doctors (including general practitioners) as per the discretion of Prof Henn. This includes procedures and consultations over weekends as well as after-hour emergencies, incl. deliveries. Appointments will be fully charge for, unless cancelled at least 24 hours in advance. I hereby give consent to the discreet disclosure of my personal and medical information to my medical aid/insurer as well as practice and hospital staff, predominantly through the use of ICD-10 codes, and I give consent to physical record keeping of consultations. In case of a complaint or dispute regarding care provided by either Prof Henn, his practice staff or locums used – I undertake to embark on a course of formal pre-mediation counselling and mediation, before any formal litigation is pursued.NameThis field is for validation purposes and should be left unchanged.
