Download Patient Consent Forms | Dr Kiran Singh Urologist Durban

Thank you for contacting Dr Kiran Singh Urology in association with Invictus Mens Health.
This is an online consultation application request, designed to minimise your in-rooms waiting time, and improve your experience with the practices.
Should you not be comfortable with completing this online form, you can complete this at the time of your appointment in-rooms. A copy will be printed for your file, prior to your consultation with Dr Singh.

Please remember to forward this document, to the practice once you receive an email attachment generated PDF.

This information will also reflect on your invoice to claim from your medical scheme/ GAP cover if applicable.

Kindly schedule your appointment request with the following websites or phone the relevant rooms.

General Urology https://www.urologydurban.co.za

Mens Health Clinic https://invictusmenshealth.com

What we as Specialist Urologists do:

Urologists diagnose and treat diseases of the urinary tract in both men and women. They also diagnose and treat anything involving the reproductive tract in men.

A Urologist is specialised in the diagnosis and surgical treatment of diseases and disorders such as Urinary Tract Infections (UTIs), Urinary Incontinence, Kidney Stones, Kidney Disease, Testicular Disorders, Enlarged Prostates, Male Infertility, Erectile Dysfunction as well as Uro-Oncology (e.g Prostate, Bladder and Kidney Cancer).

Outpatient (in-rooms) consulting days:

Monday
09h00 to 16h00
Wednesday
09h00 to 16h00
Friday
14h00 to 16h00
Saturday
08h00 to 12h00 (new patients only, NO followups)

We have admission and theatre operating rights at:

Ahmed Al-Kadi Private Hospital
Netcare Umhlanga Hospital
Life Westville Hospital

Kindly phone or WhatsApp the relevant practice, with regard to further details.

If you are unable to attend the appointment kindly cancel within 24 hours. No-shows will be billed, as we book patients STRICTLY on an appointment-basis.

At time of consultation – PLEASE SUPPLY RECEPTION WITH:

Identity card

Medical aid card

Preferred consultation date considering the above:

Date

Preferred practice location and contact person:

Ahmed Al-Kadi Private Hospital (Mayville) – Suite 4, Waterfall Suites, Basement Level of the main hospital – 490 Jan Smuts Hwy, Mayville, Durban, 4058 —— Contact person: Kamini Govender – Landline 0314923481 or WhatsApp 0659786966 or email drkiransinghurology@gmail.com

Medigate Medical Centre (Umhlanga) Suite 16a, opposite the parking lot of Netcare Umhlanga Hospital on Medigate Road – Medigate Rd, Umhlanga Ridge, Durban, 4321 ——Contact person: Dyna Reddy – Landline 0314930493 or WhatsApp 0719108915 or email drkiransinghurology@gmail.com

Relevant investigation request prior to consultation:

Blood test request (Lancet Laboratory to Ampath Laboratory)

Radiology request

Name

First Name

Last Name

Identity Number (ID) or Passport Number

Date of Birth

Date

Residential or postal address

Contact number (preferably cell/ WhatsApp)

Please enter a valid phone number.

Alternate contact number

Please enter a valid phone number.

Email

example@example.com

Employer

Occupation

Medical aid/ scheme

Medical aid/ scheme number

Medical Aid Option

Dependent code of patient

GAP cover

Yes

No

Consent

Dr Kiran Singh is a Private Specialist Urologist who charges private rates. The below information is to advise you the patient and/ or member of the practice’s charges:

R1000.00 is due at the time of your CONSULTATION, which EXCLUDES INVESTIGATIONS. Investigations performed during consultations (Ultrasound, Uroflowmetry) are billed and sent to your medical aid or settled by CARD/EFT payment at time of initial consult.

TREATMENT (medication and surgical procedures) are billed and sent to your medical aid or settled by CARD/EFT payment at time of initial consult.

All theatre procedures are billed at a rate of 300%, if you are on GAP cover then please submit the account provided after your medical aid has paid if you do not have Gap cover then rates may be discussed with Dr Singh.

Pensioners (65 and older) will not have any co- payments provided they are on medical aid with Benefit check. Pensioners will be billed at scheme rates for procedures (100%).

For more information, please refer to our website.

Acknowledge of billing structure of the practice

I (Name and Surname submitted above) have read the above provided information and understand what I am signing for.

I agree that I have been duly notified of the practice rates and should my medical aid fail to make full payment I will thereafter settle the remaining balance.

Should I not be able to afford the balance I will immediately notify the rooms and / or accounts of GJM Ultra Billing in order to make arrangements or advise of my current financial situation.

I accept that a payment arrangement may not always be applicable or may not be advisable given any or all circumstances of my account.

Terms and conditions of payment

TERMS AND CONDITIONS OF PAYMENT:ALL INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT AND ANY COST INCURRED IN RELIANCE THEREOF SHALL BE SOLELY MY RESPONSIBILITY.

IN THE EVENT OF MY MEDICAL AID NOT PAYING, I ACCEPT THAT I WILL BE RESPONSIBLE FOR PAYMENT OF THE FULL SUM OF THE OUTSTANDING AMOUNT DATED ON THE RECEIPT OF MY INVOICE.

I ACCEPT THAT IT IS MY RESPONSIBILITY TO OBTAIN AUTHORIZATION FROM MY MEDICAL AID PRIOR TO CONSULT AND TO FOLLOW UP WITH MEDICAL AID.

I ACCEPT THAT PAYMENT IS PAYABLE WITHIN 30 DAYS OF INVOICE. IN THE EVENT OF BOTH MEDICAL AID AND MYSELF, FAILING TO PAY THE AMOUNT OUTSTANDING, THE MATTER WILL BE HANDED OVER FOR LEGAL PROCEEDINGS.

I ACCEPT THAT I WILL BE RESPONSIBLE FOR ALL LEGAL COSTS INCURRED ON AN ATTORNEY AND CLIENT SCALE, TOGETHER WITH COLLECTION, COMMISSION, VAT AND TRACING FEES.

Signature

Clear

Date

To complete this submission

Please click the WhatsApp button above

Please search your email for “Jotform” and forward the PDF attachment your receive to the practice by WhatsApp above or email to drkiransinghurology@gmail.com

PLEASE CLICK SUBMIT BELOW

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CONSENT FORM DOWNLOADS

Minor Endoscopic

Major Open Surgery

Scrotal and Genital

Other

A DIVISION OF

Online consultation application:

durban-medical-centre-slide1 durban-medical-centre-slide2 durban-medical-centre-slide3 Durban Medical Centre
	Suite 1204, 12th Floor, Durban Medical Centre, 94 Charlotte Maxeke Street (Former Beatrice Street) Durban, 4001
	(031) 492-7310
	065 978 6966
	drkiransinghurology@gmail.com

ahmed-al-kadi-private-hospital-slide1 ahmed-al-kadi-private-hospital-slide2 ahmed-al-kadi-private-hospital-slide3 ahmed-al-kadi-private-hospital-slide4 Ahmed Al Kadi Private Hospital
	Suite 4, Waterfall Suites , Basement Level, 490 King Cetshwayo, Mayville Durban, 4058
	(031) 492-3481
	065 978 6966
	drkiransinghurology@gmail.com

melgate-medical-centre-slide4 melgate-medical-centre-slide1 melgate-medical-centre-slide2 melgate-medical-centre-slide3 Medigate Medical Centre
	Suite 16 Medigate Medical Centre, Gate 2 (Opposite Netcare Umhlanga Hospital) Medigate Road Umhlanga Rocks 4319
	(031) 492-3481 / (031) 492-7310
	065 978 6966
	drkiransinghurology@gmail.com