+27 (0)16 931 0217/9
+27 (0)82 319 6727
V a n d e r b i j l p a r k
14 Hertz Boulevard
P a r y s
85 Buiten Street
Patient registration form
Complete prior to your appointment with dr Lourens Coetzee.
All fields with a * are mandatory.
Please complete as many fields as possible.
Main member information
Next of kin
(not from the same physical address)
Hereby I confirm that the information I supplied is true
If your form does not submit:
Ensure all mandatory fields marked with an * are completed
Please note that you (or your parent or 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.