Patient Jobcard Please kindly complete the below information and hit the submit button. Patient Jobcard PARKLANE RADIOLOGY Patient Jobcard Benefit Ref#:PATIENT DETAILS Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Date of birth(Required) MM slash DD slash YYYY ID No. (Member)(Required) Relationship to member: Phone(Required)Email(Required) Section BreakPERSON RESPONSIBLE FOR ACCOUNT Name(Required) First Last ID No. (Member)(Required) Physical Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Section BreakMEDICAL AID Scheme name:(Required) Membership number:(Required) Plan:(Required) Dependant code (patient)(Required) Section BreakFRIEND / RELATIVE INFORMATION Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Phone(Required)Section BreakREFERRING DOCTOR Name(Required) First Last Phone(Required)I, the undersigned, being duly authorised hereto, agree to all the stipulations and conditions herein and in the company's Standard Terms and Conditions. Name(Required) First Last Consent(Required) I agree to the Terms & ConditionsPayment of the account in accordance with tariff charges prevailing in the practice shall be the responsibility of the undersigned/patient. In the event of the account not being timeously settled in full by the above signed, then interest at a rate equal to 2% per month on the outstanding balance will be payable thereon, until the date on which it is settled in full. I undertake to be liable for all legal costs between attorney and client, as well as tracing and collection fees due, should it be necessary for legal action to be taken, for the recovery of any amount owing or arising out of treatment received by the above patient. I consent to your being entitled to obtain credit and related information concerning myself at any time and lodge/exchange and disclose such information with any credit bureau without any further notice to me. I further consent to your being entitled to disclose any medical information regarding the above patient to my medical aid, as they require. I confirm that I am aware that the practice may make the X-ray and other digital images taken by the practice, available in a digital electronic form to medical practitioners.
