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DR EMMANUEL R. TLOU
CLINICAL PSYCHOLOGIST
PR. No. 8623694

PERSONAL DATA SHEET

A. PARTICULARS OF CLIENT

Surname:		Title:
Name(s):
Date of Birth:
ID Number:
Relationship to Main Medical Aid Member:
Postal Address:
		Code:
Residential Address:
		Code:
Telephone Numbers:	Home:	Cell:
	Work:
Fax Number:
Email Address:
Employer:
Employer Address:
		Code:
House Doctor:	Name:
	Telephone:
Medicines Currently Using:
Referred by:
Next of Kin:	Name:
	Telephone:

B.PARTICULARS OF SPOUSE / PARTNER (Where applicable)

Surname:
Name (s)
Telephone Numbers	Home:	Cell:
	Work:
Email Address:

C.MEDICAL AID DETAILS

Medical Aid:		Option:
Medical Aid No.
Main Member:
ID No. of Main Member:

D. PARTICULARS OF PERSON RESPONSIBLE FOR ACCOUNT*

Surname:
Name(s):
Date of Birth:
ID Number:
Relationship to Client:
Postal Address:
		Code:
Residential Address:
		Code:
Telephone Numbers:	Home:	Work:
	Cell:
Fax Number:
E-Mail Address:
Employer:
Employer Address:
		Code:
* Fill in if different from person in Section A of this form. CONTRACTUAL TERMS The practice is not contracted to any medical aid and charges private fees (refer to fees schedule in the practice website). Medical aid clients are required to pay the difference between the practice’s tariffs and medical aid tariffs. Discounted fees (10% off) apply to clients who settle in full before the session. Payment of fees is the client’s responsibility. Medical aid clients are required to complete a debit order mandate authorising account administrators, V Professional Services (Pty) Ltd , to recover unpaid fees (Click here to download debit order mandate form). Appointments should be cancelled 24 hours in advance, e.g. a 17h00 appointment on a Monday must be cancelled before 17h00 on the preceding Friday. No-shows are charged a full session fee. Session end times are not adjusted to accommodate late coming, e.g. a 10h00 session scheduled to end at 11h00 will still end at 11h00 even if the client arrived at 10h30. A full hour’s fee will still be charged. The practice’s premises are entered and exited at own risk. ……………………………………………… 23-02-2012 SIGNATURE OF CLIENT DATE (OR GUARDIAN IN THE CASE OF A MINOR)