Pa sin t in l ig t in g / pa t ien t in f o r ma t io n

Van / Surname
Volle name / Full names
Posbus / PO Box Address
Woonadres / Home Address
Kontaknommers / Contact Numbers
(H) __________________________ (W) ___________________________ (S) ) ___________________________
(F) ___________________________ (eMAIL) ________________________________________________________

M EDIESE FONDS / M EDICAL AID

MEDIESE FONDS / MEDICAL AID
Plan / Option
Lidnommer /Membership Number
Voordeeldatum / Benefit Date
Uitsluitsels / Exclusions / Waiting period

INLIGTIN G SOOS OP Lid k a a r t / M ember sh ip c a r d INFORM ATION

Pasient kode
Dep. Code

Afh / Dep

Volle Name van HOOFLID en ALLE Afhanklikes

Full Names of MAIN MEMBER and ALL Dependants

Geslag
Sex
M

Id. Nommer / Geboortedatum

Id. Number / Birth date

Al l er g ie & K r o n iese Siek t et o est a n d e

Al l er g ies & Ch r o n ic d isea ses
Naam / Name
Volledige Besonderhede / Full Details