I/We hereby undertake to liquidate any amount due to Dr. with regards to any medical fees either partially covered or not covered by my medical scheme. I/We furthermore accept that any amount inclusive and less than R 500.00 (five hundred Rand) may be placed on single debit order and continue until all amounts due are fully paid up by me. I/We further undertake to cover all costs relating to debit orders initiated, when no funds are available in my account after the 30th day of any given month. I/We confirm that the information supplied in this form by me/us is correct on signature thereof.

Account Name:    
Branch: Code:
Account Number: Account Type:

I/We hereby instruct and authorise you to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commencing on the date I/we are informed of the Medical Aid short or non-payment and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as set out in the Payment Schedule above .In the event that the payment day falls on a Saturday, Sunday or recognized public holiday (as stipulated by the Public Holidays Act), the payment day will automatically be scheduled for the pre-ceding ordinary business day, or alternatively, the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account; I /We understand that the withdrawals hereby authorized will be processed through a computerized system provided by the Banks and I also understand that details of each withdrawal will be printed on my bank statement or on an accompanying voucher. This reference number, if provided to you should enable you to identify the Agreement / Contract. The Contract number is stated above, and has been communicated to me directly after having been issued by you. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

I/We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.

I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

Signed at: on this day of 20

Name of person responsible for account:
Email Address: