top of page

1.Patient Details

2.Medical Aid

3.Details of Main Member

Person Responsible For Account

4.Next of Kin

5.Authorisation

I agree that the address above is my chosen domicilium citandi et executandi for purposes of delivering and serving of all invoices, documents and legal processes. I further agree that in the event of medical aid not paying any award due for whatsoever reason, that I am still liable in my personal capacity to pay the amount owing. I further agree that in the event of my account being handed over to attorneys, that I will pay all attorneys fees and costs on attorney and client scale together with further collection commission.

bottom of page