Patient intake form

To help you understand how things work here at VLMC, we have provided our payment agreement bellow.

Payment agreement

Once-off upfront fee payable on the day of service for Medical Aid Patients

R850.00

Once-off upfront fee, payable on the day of service for Private Patients

R2 000.00

Follow-up for return visits For All Patients (Excluding materials)

R350.00

ALL MATERIALS ARE CHARGED SEPARATELY AT AN ADDITIONAL COST

PLEASE NOTE: The levy is a once-off administration fee that is due on the first visit and is non-refundable by medical aids. The wound clinic will submit a request for authorisation to your medical aid for advanced wound care on your behalf. Once approval is received, all claims will be submitted directly to you medical aid by our administrators. If authorisation is declined, the patient remains liable to settle the full account within 14 days.

Please ensure that you have a referral letter from your doctor, your ID and medical aid card to avoid delays in authorisation approval.

PLEASE NOTE: You will be held liable for any amount not paid by medical aid.

Terms and Conditions

I understand that I am fully responsible for payment for services rendered.I understand that I will be liable for debt recovery costs, should I not pay timeously.I understand that my Medical Aid may or may not cover all the fees charged by this practice.

I/we, the undersigned, hereby authorise Van Lendt Medical Care and their Accounts department to disclose the nature of the patient's diagnosis and/or any health services rendered to the patient; to the patient's medical aid, and I/we confirm that Van Lendt Medical Care and their Accounts department may use the email addresses and contact numbers as indicated in the patient/guarantor details for communication purposes on accounts and/or invoices, or submission thereof and may use my personal information for purposes of collecting and recovering any amounts owed by myself.

Where the patient is a minor, that is unmarried and below the age of 18 years, both the minor's parents and/or guardians sign these terms and conditions in both their personal and representative capacities and in so doing accept responsibility for payment of the fee in full. If only one parent/ guardian signs these terms both parents shall be held jointly and severally liable for services rendered to such minor patient.

I understand that I remain liable for any unpaid accounts & that I will be liable for legal costs, should I not pay timeously I authorise Van Lendt Medical Care to disclose my diagnosis and personal information to my medical aid and to her Accounts department for the purposes of claim submissions and/or debt collection. 

Patient information

Account holder info

If you are a Medical Aid Patient, Please submit the details of the individual who is the account holder. If you are the account holder, please resubmit you information bellow.

Booking

Van Lendt Medical Care consultations:

Monday - Wednesday - Friday

08:00 - 15:00

Kindly note the practice operates on a first come, first serve basis, as treatment times vary depending on the extent and duration of procedures.