PATIENT DETAILS FORM
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Please note that the practice is contracted out of medical aid. Please pay and claim back directly from the medical aid. I agree to be liable for all legal and/or collection costs arising in the event of failure to settle my account in full within 30 days
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Choose suitable time* 9:0010:0010:3011:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:30
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