New Patient Registration

1 Personal details

Full name and surname

ID / passport number

Date of birth

Gender

Female

Male

Other

Prefer not to say

Occupation

2 Contact details

Cellphone number

Email address

Physical address

3 Medical aid

I am a self-paying (cash) patient — no medical aid

Medical aid scheme

Membership number

Main member's name

Dependant code

4 Emergency contact

Name

Relationship

Phone number

5 Medical history

Known allergies (medication, food, other)

Current medication

Chronic conditions

Previous surgeries / hospital admissions

6 Consent

Your information is encrypted on your own device before it is sent. Only Dr Daniel's practice can decrypt it.

I confirm the information above is accurate and I consent to treatment

Full name as signature

Date