ACKNOWLEDGEMENTS AND UNDERTAKINGS
The Patient Data Form reviewed and/or completed by you will be deemed to form part of this admission form. You acknowledge that you have reviewed all of the details contained in the Patient Data Form and that all of these details are true, correct and accurate as at the date of signing this admission form.
Where this admission form is signed electronically, this admission form has been signed by way of an electronic signature. A copy of the signed admission form and the Patient Data Form will be emailed to you, for your records and future reference. Please let us know if you do not receive your copy by email. The provisions of the Electronic Communications and Transaction Act (ECTA), in relation to the conclusion of electronic agreements and the validity of electronic signatures, will apply to this admission form.
By signing this admission form, you agree to be bound by its terms and you acknowledge that you have read all of the terms of this admission form carefully. This admission form will be legally binding, valid and enforceable, notwithstanding that it has been concluded and signed electronically, that each page of the document has not been initialled by you and that your signature has not been verified by a witness.
Where this admission form has been signed on behalf of a minor child (under the age of 18), you acknowledge and confirm that you are a competent person (e.g. parent or legal guardian) authorised to sign this admission form for and on behalf of the minor child.
2nd Floor, Fountain View House, Building 9, Constantia Office Park, Corner 14th Avenue and Hendrik Potgieter Street, Johannesburg
Tel: +27 (0) 87 087 0600
GPS: -26.104922, 28.055648
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