New Client Form

Personal Details

*
*
*
*
If minor, parents details to follow below
*
*
*
If different from Postal Address
*

Emergency Contact Person

*
*
*

Medical Aid Details/Person responsible for account - if applicable

The practice of N Macleod Biokinetics is contracted outside of medical aids, payments are to be made to the practice directly, in advance, and specified accounts will be provided within 10 days for clients to submit to their medical aid for reimbursement. Only full rates are claimable, all discounted/package rates are NOT claimable. 


Payment Method

*
EFT - First National Bank
Account name: Body Innovation (Pty) Ltd
Branch: Remote branch
Branch code: 250655
Account number: 62749943157
Ref: Name & Surname
 
Credit Card/Paypal - Online Store Payment

Medical History

Tick if you have ever been diagnosed or suffered any of the following;*

Policies/Indemnity

I hereby accept the above terms and conditions*
*
*
Type Initial and Surname

Marketing Information

How did you hear about Body Innovation
Would you be happy to receive our specials and newsletters
(this information is not shared and contact is made on average 1-2 times per month)
How did you first contact us