Forms

Patient Contract
Download Form Here

MAIN MEMBER OF MEDICAL AID / PERSON LIABLE FOR ACCOUNT

















[address chosen as my domiculium citandi et executandi where all legal notices pertaining to my account can be served on me]








PATIENT INFORMATION:













Next of kin not living with you:



MEDICAL AID INFORMATION:







Pasient Kontrak
Download Form Here

HOOFLID VAN MEDIESE FONDS /REKENINGPLIGTIGE

















[adres word aangewys as my domicilium citandi et executandi, synde die adres waar alle regskennisgewings wat op my rekening betrekking het, beteken kan word]








PASIëNTINLIGTING:













Naasbestaande wat nie by u woonagtig is nie:



MEDIESE FONDS INLIGTING:










Authorization for Procedures
Authorization for Procedures (Afrikaans)
Cureday Pre Admission Form
Netcate Pre Admission Form

Contact Us

14 + 11 =

Dr Hendrik P Ehlers

Reception

Charmian Lamprecht

012 998 9133

064 680 1507

reception@drhpehlers.co.za

Accounts

Coleen Harmse

012 998 9133

064 680 1507

accounts@drhpehlers.co.za

Theatre Bookings

Colette Lippold

012 998 9133

064 680 1507

theatre@drhpehlers.co.za