Parent/Guardian

Emergency Contact (not one of the caregivers previously mentioned)

Account Details

Medical History

Or:

I hereby certify that to the best of my knowledge the information provided on this form is true and correct.

Because my child is a minor, I give consent for his/her examination and treatment furthermore.

I will be responsible for any financial obligations incurred for my child’s treatment and also for incidental costs, and or legal fees necessary to recover the same. I am aware that accounts are to be finalised at every appointment.

We have a 24 hour cancellation policy, any appointment cancelled later than this may incur a cancellation fee. We ask that you advise us via phone call as soon as you know you are unable to attend your appointment.