Intake Questionnaire

Hello,

You have recently made an appointment to see Dr Christina van der Merwe at her offices in Dormehlsdrift, George.

To faciliate this appointment, I would appreciate you complete this online form and send it back to me as soon as possible. It has 4 sections to it, and should take you no longer than 5 minutes.

Please be as accurate as possible as this information is used to facilitate the invoicing and medical aid enagements after seeing me.

Thanks in advance.
Christina.

PS: please don't click on any of the menu items at the top until you have submitted the intake form as this will purge all the information.

All required fields are marked with an *

Personal Details

Title *

First Name *

Surname *

e-mail *

Repeat e-mail *

Cell Phone

ID Number

Date of Birth *

Person Responsible Tip

Name (First and Surname) *

ID Number

Cell Phone *

Street Address (Person Responsible) *

Province*

Country

Employer Name

Occupation

Work Phone

Employer Address

Province*

Country

Street Address & Postal Address Tip

Same address as Person Responsible Street Address*

Yes
No

Postal Address

Province*

Country

Medical Aid Information

First Name of Member

Surname of Member

Initials

Dep. Code

First Name Patient

Surname of Patient

Initials

Dep. Code

ID Number

Medical Aid Name

Medical Aid Number

Agreement Conditions*

As you are entering into a contract with Dr Christina van der Merwe, the processing of your personal data is necessary. I take the storing and accessing of your personal information very seriously and confidentiality is of utmost importance. Your personal information will be stored securely at all times and only accessed by me. Further information about my practice and personal data:

• I am a registered Clinical Psychologist with the Health Professions Council of South Africa (HPCSA). This registration (PS0028797) allows me to practice in South Africa.

• According to the HPCSA regulations, I keep patient files for a period not exceeding 6 years.

• All client notes are stored separately from identifiable information and are password protected as they are stored electronically.

• Invoices are not emailed directly to medical aids and it is the 'person responsible' for the account who must submit this invoice to the medical aid.

• Medical aids require an ICD 10 Code (diagnosis) on your invoice for payment of claims.

• I use Bookeo ® calendar for booking of appointments.

You hereby consent to the processing of your personal information contemplated in the Protection of Personal Information Act No.4 of 2013, by Dr Christina van der Merwe (Clinical Psychologist), the practice staff and third parties with whom Christina has a contractual relationship for the following purposes:

• Treating and managing you in terms of a psychologist-and-patient relationship;

• The administration of the contractual relationship between yourself and Christina van der Merwe;

• Communicating with other persons as it relates to treatment and management will only occur with the individuals consent;

• Communicating with third parties who have undertaken to indemnify you for the costs of your treatment and management or part thereof including medical schemes and their administrators where relevant; and

• Collecting monies outstanding from you.

I agree