Referral Letter Click here to download as a PDF Personal Information - Patient Patient Names and Surname If minor, state name of parent or guardian ID Number Date of birth Gender MaleFemale Referring doctor Patient contact number Have you been in a hospital in the past two years? YesNo Have you been under the care of a doctor during the past two years? YesNo Any medicine or drugs during the past two years? YesNo Are you allergic to Penicillin / any other drugs or medicine? YesNo Have you had any excessive bleeding requiring special treatment? YesNo Have you had any other serious illnesses? YesNo If Applicable: Are you pregnant? YesNo Tick the name of any of the following which you have had Heart DiseaseHeart MurmurHigh Blood PressureRheumatic FeverAsthma, CoughDiabetesTuberculosisHepatitisHIVJaundiceArthrithisStrokeEpilepsyPsychiatric Treatment Agreement I, undertake to pay all costs as between attorney and client as well as collection commission of 10% in the event of instituting any legal action emanating from this document / transaction against me/us. I agree to pay any account received within 30 (thirty) days of statement date and acknowledge that I will pay the interest per month on any unpaid balance owing by me. Person responsible for payment of account / Main member Names and Surname ID Number Home Address Postal Address Home Tel Work Tel Cell Email Medical aid details Medical Aid Medical Aid No Medical Aid Plan Authorization No Other Telephone Numbers Wife/Mother Husband/Father Relative/ Friend Submit
