The above information is true to my knowledge. I hereby give permission for treatment for myself/ my dependant. The account is rendered separately from any other medical accounts. I authorise the practice to release any clinical information and information required to process my claims or to collect outstanding balance on overdue accounts. I understand that I am financially responsible for payment. Arrear payments will be allocated to interest, cost then capital. I agree that in the event of any legal action instituted against me, I will pay all legal costs on the attorney and own clients scale and any teaching costs and charges stipulated by the Debt Collectors Act 114 of 1998. I hereby acknowledge and agree that any information regarding credit worthiness, defaults in payment and details of how the account is conducted may be disclosed to any other creditor or the applicant or to one or more Credit bureaus. I hereby acknowledge that tracing on this agreement is allowed. I choose the above address as my domicillium citandi et executandi for all purposes arising from this agreement. Appointments not cancelled with 6 hours will be charged for. The terms and conditions in this consent form will be applicable if there are any subsequent/repeat procedures and future consultations. Should your details change, it is your responsibility to update them with the rooms, by completing your new details on a similar form and resubmitting these to the practice.