Book Now DR SINEZIWE MULONGA Step 1 of 2 - Main Member Information 50% X/TwitterThis field is for validation purposes and should be left unchanged.All fields with * are mandatory.MAIN MEMBER INFORMATION:ID NUMBER*SURNAME*FULL NAMES*INITIALSGENDERMALEFEMALETITLEMRMRSMISSMSDRDATE OF BIRTH* DD slash MM slash YYYY HOME LANGUAGEENGLISHAFRIKAANSISIZULUXHOSAOTHERMAIN MEMBER CONTACT DETAILSCELL NUMBER*HOME NUMBERWORK NUMBEREMPLOYERFAX NUMBEREMAIL ADDRESS* EMAIL STATEMENTYESNOPOSTAL ADDRESS* Street Address Address Line 2 City Postal Code PHYSICAL ADDRESS* SAME AS PREVIOUS Street Address Address Line 2 City Postal Code MEDICAL AID DETAILSMEDICAL SCHEME*PLAN/OPTION*GAP COVERYESNOMEMBER NUMBER*MAIN MEMBER DEPENDANT CODE PATIENT INFORMATIONID NUMBER*SURNAME*FULL NAMES*NICK NAMEINITIALSGENDERMALEFEMALETITLEMRMRSMISSMSDATE OF BIRTH* DD slash MM slash YYYY HOME LANGUAGEENGLISHAFRIKAANSISIZULUXHOSAOTHERPATIENT CONTACT DETAILSCELL NUMBER*Use this number for appointments / test results?YESNOMain member's Cell Phone number will be used if the above is NoHOME NUMBERWORK NUMBEREMAIL ADDRESS PATIENT PERSONAL INFORMATIONOCCUPATIONMARITAL STATUSRELATIONSHIP TO MAIN MEMBERPATIENT DEPENDANT CODE*AGE (years)HEIGHT (m)WEIGHT (kg)REFERRING DOCTORTELEPHONE NUMBERPATIENT NEXT OF KIN (Not from the same physical address)INITIALSTITLEMRMRSMISSMSSURNAMEFULL NAMESCELL NUMBERRELATIONSHIP TO PATIENTHereby I confirm that the information I supplied is true and I am responsible for any false information providedFULL NAME IN PRINT*DATE OF SIGNATURE* DD slash MM slash YYYY SIGNATURE*Keep up to date and receive notices from the practiceYESNOAll fields with * are mandatory. Please note that you (or your parent/guardian) remain liable for the account for services rendered by this practice, even if you are insured by a medical aid or other third party. Please ensure that you have read and signed the attached Doctor-Patient contract.
