Forms

Patient Details Form

PATIENT DETAILS

In submitting this online form, I agree to Dr Melvill including ICD10 codes on all statements and invoices. Furthermore, I accept that I am responsible for the settlement of my accounts and I have read and understood the information provided on this web page. I agree that the fees for services rendered will exceed those of the National Health Reference Price List.

Due to COVID-19 we now request that all patients complete the take-on form online prior to your first appointment or a follow up appointment should your details have changed. If you prefer to complete a form in pdf format, download here.

Please contact Natalie prior to your consultation with regards to consultation fees.

Billing

With regards to your account, please understand that your medical aid decides independently what contribution it is prepared to pay on your behalf, depending on your status with them. You will always be responsible for a portion of your account and for submitting your account to your Health Funder. Your portion can be reduced if you take advantage of the discount offered for payment on the day of the consultation and/or surgery.

Please note that this practice will charge interest at 2% per month on all overdue balances, including R50.00 administration fee. The practice reserves the right to employ the service of a Credit Bureau to trace or list you as a slow / delinquent payer, should payment not be settled in full by 60 days.

NOTE: Please be aware that WE DO NOT NEGOTIATE FEES for any other person involved with surgical procedures, such as anaesthetists, etc.

Auxillary Services

Fees may be charged for the following: Telephonic Consultations – Motivation Letters – Medical and /or Insurance Reports – MVA Forms – Duplicate Copies of Prescriptions – Repeat Prescriptions without the patient being present, Facsimiles and Extracts from Medical Records.

X-rays and Scans

Cape Radiology produce images on CDs (compact discs) that can be read on any computer. If you wish to have copies of your images please make a request for your CD at the X-ray Department.

Telephone Communication

Should you ever need to contact Dr Melvill by telephone please phone the office during office hours and Dr Melvill’s home number after hours. The mobile phone is often not answered because of poor reception. Leaving voice mail and SMS messages is to be avoided as these messages may go unanswered. DO NOT COMMUNICATE VIA VOICE MAIL, SMS AND WHATS APP!

ICD-10 Diagnostic Codes

On completion of the online form you agree to Dr Melvill including ICD-10 codes on all statements and invoices.

Digital Signature and Agreement

On completion of the online form you accept that you are responsible for the settlement of all Dr Melvill's accounts and understand the above in full especially with regards to telephonic communication. Furthermore you agree that the fees for services will exceed those of the National Health Reference Price List.