Patient Information Sheet Patient Name * First Name Last Name Phone * (###) ### #### Date of Birth * MM DD YYYY Name of Person Responsible for Account * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medical Aid * Medical Aid Number Do you give permission for ICD10 codes to be shown on your invoice for medical aid purposes? * Yes No Patient Confirmation: * 1. I hereby confirm that the information furnished above is correct 2. I understand that Melanie Lotter is contracted out of Medical Schemes and that I am personally liable for settling each account. 3. I understand that in accordance with the POPI Act of 2013; *All data provided herein will be captured and stored electronically with all reasonable measures put in place to prevent unauthorised access to your personal information. *Melanie Lotter Occupational Therapist will not sell or disclose your personal information to any third party without your consent. *Melanie Lotter reserves the right to disclose your personally identifiable information to governmental or regulatory authorities if required to do so by law. Your Name and Date: Patient Signature * Thank you!