Patient Details Complete the form below with your information after you have made an appointment for your patient details in our files. Patients Details Patient's Information Dropdown * MsMrMrsMissDrProfOther Full Names (As on your Medical Aid) * Preferred Name * Surname (Lists of all used for admin purposes) * ID Number * Email * Phone * Gender * FemaleMaleAgenderAllGender NeutralTransgenderNon-binaryGenderqueerTwo-spiritThird GenderPangenderCombination Marital Status * SingleMarriedDivorcedEngagedSeparatedDomestic PartnershipWidowWidowerOther Occupation * Employer * Work Phone Which psychiatrist did you see last? When was the last time you saw them? Who referred you to our practice? * Preferred Language Afrikaans English Medical Aid Details If you are not part of a Medical Aid, please leave this section blank and continue directly to the Person Responsible for Account section and complete the relevant information. Medical Aid Name Plan Medical Aid Number Dependent Code Main Member same as Patient Yes Dropdown MsMrMissMrsDrProfOther Name Surname ID Number Relationship SelfSpouseParentChildSiblingAuntUncleCousinGuardianOther Phone Email Person Responsible for Account Select if the Person Responsible for Account is the Patient, Main Member or Other. If Other/Private Paying is selected, please complete the section below. If patient or Main Member is selected, skip this section and go to the next one. Person Responsible for account is * Patient Main Member Other/Private Payment First Name Surname ID Number Relationship SelfSpouseParentChildSiblingAuntUncleCousinGuardianOther Phone Email Residential Address * Postal Code * Occupation Employer Next of Kin and Emergency Contact Name * Surname * Phone * Email Relationship * SpouseParentChildSiblingAuntUncleCousinGuardianOther Residential Address * Postal Code * Payment Terms & Conditions Outstanding accounts result in stress and pressure, which is counterproductive to our treatment. For this reason, we cannot provide non-emergency services if an account is outstanding or where private rates apply and cannot be paid. If you find that our rates are too high and you are an existing patient, speak to Dr to refer you to another clinician or institution. Outstanding accounts are payable in advance & proof of payment should reach firstname.lastname@example.org before your consultation. If the estimate paid is more than the actual time = money amount, a refund will be done in three work days. For your convenience, we submit claims to medical aids. The patient/guarantor is responsible for any short payments. All other types of claims should be settled by the patient/guarantor and the money recovered from the third party (Workman’s Compensation Fund, Road Accident Fund, Trust Accounts, Medical Insurance) by the patient/guarantor. Services are charged per individual Medical Aid rates. According to the National Credit Act, we may not provide any credit as we are not registered credit providers. Your responsibilities and suggestions regarding being proactive about medical aid payments: It is your, patient/guarantor, responsibility to resolve discrepancies regarding non-payment by your medical aid. You should ask your medical aid about any rules that apply to your plan for you to see a Psychiatrist. They might ask for our practice number: 017 1131 Should your medical aid require an authorisation or referral for out-of-hospital specialist consultations, this authorisation is to be obtained by you, from your medical aid. You should communicate any limits set on payment regarding procedure codes i.e. “they will only pay 2 X 0162 and 6 X 2974” As per all medical aid rules; authorisation is not a guarantee of payment. Ask them which benefit pocket the money will come from and if there is money available in that benefit pocket. The patient/guarantor remains personally responsible to ensure that he/she is attentive to all appointment dates and times. Appointments not kept due to date and time errors will be charged for. If uncertain about appointments, please phone the practice to confirm. Appointments not cancelled 48 hours in advance will be charged for at the applicable medical aid tariff based on the time booked out for your appointment. Regarding underaged children, the parent who signs, confirms that he/she informed the child’s/children’s other parent and has the consent of the other parent for the assessment and/or therapy. In the event of a divorced or minor client, the person signing this agreement remains personally liable for the payment of the account, even in cases where the previous spouse or parent is liable for the payment of medical expenses. Personal particulars are voluntarily disclosed by the client and will form part of the permanent confidential file, which will remain the property of the practice. The contact details given on the Patient Information Sheet is DOMICILIUM CITANDI ET EXECUTANDI for receiving documents and letters for execution. Should legal action result from the efforts to recover any amounts in arrears, the undersigned accepts liability for all legal costs on an attorney and own client scale, including collection, commission, tracing fees and the likes thereof. I, the undersigned, personally accept responsibility to see to the payment of the account, as well as to abide by the above-mentioned conditions. The undersigned understands and authorizes that claims submitted to a medical aid require an ICD 10 or diagnoses code. The following applies to all patients: Unless you have completed a PMB document, signed and sent it to us, and we could reasonably establish and confirmed with you that the PMB will be or was approved, the First Consultation is payable by the patient. If you have paid, you will receive a statement and may claim back from your medical aid. The initial consultation fee is chargeable in conjunction with the price for Individual Psychotherapy. Additional fees chargeable with or without the presence of the patient Telephonic consultations Prescriptions Note to 3rd Party (written/telephonic) Completion of PMB / chronic illness benefit (written/telephonic) The writing of a report to a 3 POPI & PAI Conditions We are committed to protecting your privacy and to ensuring that your personal information is collected and used lawfully and in the course/alliance with best healthcare practices. For us to fulfil our duties, your (the patient) & the main member’s personal information, has been/will be processed/shared regarding; The solution is provided (treatment) to you (the patient) with your best interest in mind. The administration and the contractual relationship between yourself (or guardian) and the company, Dr Jerrie in a Nutshell. Operators may include medical aids and outsourced services where, for example, we require assistance with collecting fees. Note that accounts to medical aids lawfully have to include ICD-10 codes, which disclose your diagnosis. Where third parties are pertinently relevant in assistance in and/or treatment and managing you, the patient, from a clinical or general improvement perspective. Processing anonymous information for research and solution development. Should you qualify, we require permission to assist you in applying for PMBs (Minimum Prescribed Benefits) from your Medical Aid. Outpatient interventions specifically use PMBs, and these will affect inpatient benefits. It is of utmost importance that you inform us to cancel this instruction if need be. 7. Please note that the cost of healthcare sometimes depends on how your body reacts to treatments. The law allows us to step in to save your life or to prevent or reduce harm to you. By Clicking this, you are confirm that you read and understood the Practice Terms and Conditions above. * I accept the Terms and Conditions May we apply for the PMB benefit on an ongoing basis each year? Yes No I have read and understood the POPI & PAI Conditions. * I accept and understand. Notifications like appointment reminders, should be sent to me via * Phone call/SMS Email WhatsApp If you are human, leave this field blank. Submit Please complete the Story of My Life questionnaire next.