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Ms Mrs Miss Mr Prof Dr
For how long
Home Tel No
If residential address has changed within a year, please give:
Business Tel No
For How Long
Spouse or relative's full names, address & contact number(if student, state parent's contact details):
Name of Main Member
Medical Aid No
How long a member
Name & address of family/friends staying at a different address
I certify that the above information is correct.
IF ANY MEDICAL AID DOES NOT PAY ANY CLAIMS OF DIE BOORD/MEDI-HEALTH/STELLENBOSCH SQUARE/EIKESTAD MALL PHARMACY ON MY BEHALF, I CONSENT THAT THE FULL AMOUNT OF REJECTIONS BE CHARGED TO MY ACCOUNT.
If I do not pay the current balance on my account within 30 days, I consent that interest be added at 22,25% per year.
I undertake, if I do not pay the current balance on my account within 30 days and it is handed over to attorneys for collections, to pay all legal costs to attorney and client scale, including collection commission at 10%, as well as tracing costs, if applicable.
If any of the above-mentioned information changes, I undertake to inform the pharmacy within 14 days in writing by registered post or by hand of such change.
I consent to the jurisdiction of the Magistrate’s Court, notwithstanding the amount of the claim. For the purpose hereof, I choose domicilium citandi et executandi at the above-mentioned address.
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