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Person responsible for payment / Medical Aid Details:



Terms and conditions of payment:


All information provided herein is true and correct and any cost incurred in reliance thereof shall be solely my responsibility. In the event of my medical aid not paying, I accept that I will be responsible for the payment of the full sum of the outstanding amount dated on the receipt of my invoice. I accept that it is my responsibility to obtain authorisation from my medical aid prior to consult, and to follow up with my medical aid.

I accept that payment is payable within 30 days of invoice. In the event of both medical aid and myself failing to pay the outstanding amount, the matter will be handed forward for legal proceedings. I accept that I will be responsible for all legal costs incurred on an attorney and client scale, together with collection, commission, VAT and tracing fees.

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