PERSON RESPONSIBLE FOR THE ACCOUNT (if not the same as the patient, please give details, i.e. including initial, surname and address)



To avoid any misunderstanding the following information is provided as a guide.

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 contact reception to enquire about consultation costs and discounts.


Please be aware that we do not negotiate fees for any other person involved with surgical procedures, such as anaesthetists, etc


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.

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.

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 community via voice mail, SMS and WhatsApp!


By completing and sending this form you agree to ICD10 codes being used on all statements and invoices.

By completing and sending this form you accept that you are responsible for the settlement of your accounts; all fees for services rendered will exceed those of the national health reference price list.

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. In the event of legal action being taken against you for recovery of any amount whatsoever, you shall be liable for all legal costs incurred.

By signing and sending this form you acknowledge and give your authority for these actions that involve the release of personal information and that you understand the privacy policy which is available on this site.