Surname: _______________________________ Initials: ______________ Title: _______________________
First Names: ______________________________________ ID number: ______________________________
Home Tel: ____________________ Work Tel: ____________________ Cell: _________________________
E-mail address: ___________________________________________________________________________
Postal address: ____________________________________________________________________________
______________________ Code:________________ Physical address: ______________________________
Occupation: ___________________________________ Employer: _________________________________
Employers address: ________________________________________________________________________
Medical aid details
Medical aid name: _________________________________________________________________________
Option: __________________________________ Medical aid number: ______________________________
Main member: _________________________________ ID number: __________________________________
Next of kin/Relative
Full Name: ________________________________________________________________________________
Home Tel: ________________________ Work Tel: _____________________ Cell: ____________________
Do you suffer from any of the following?
Are you allergic to iodine or any other medication? Y N
If yes, what medication are you allergic to? ______________________________________________________
Have you ever had local anaesthetic? Y N
Are you on Warfarin or any other anti-coagulant? Y N
What medication are you taking at present? ______________________________________________________
• This practice does not submit accounts to medical aids. It is your responsibility to settle your account in full.
You will be provided with a detailed statement and proof of payment to submit to your medical aid for
reimbursements. Payments may be made by means of credit card, debit card or cash.
• Price increases may be levied from time to time
• Devices can take between 2-3 weeks to manufacture as they are custom made • The device may need adjustment after fitment • Alternative footwear may need to be considered
Appointments not kept or cancelled at least 12 hours before will be billed at a full consultation rate
I understand that I am fully responsible for my account and not my medical aid. I understand that I am to settle
Please note that if payment is not made within 60 days, the account will be handed over to our attorneys for
collections. You will be held liable to pay any collection and/or attorney fees on the Attorney Client Scale.
Name: _________________________Signature: ____________________ Date: _______________
Southend Gastroenterology Associates, PLLC Sanjay Jain, MD Colonoscopy 4402 Churchman Ave, Suite 408, Louisville, KY 40215 Colyte Preparation Instructions Please follow the following instructions one day prior to examination. 1. Prepare the colon prep by filling the gallon jug to the fill line with tap water, shake well, and set on the counter. Do not refrigerate. 2. That mornin
Observation of Lunar Impact Flashes with the SPOSH Camera: System Parameters and Expected Performance R. Luther (1,2), A. Margonis (2), J. Oberst (2,3), F. Sohl (3) and J. Flohrer (3) (1) Humboldt Universität zu Berlin, Germany, (2) Technische Universität Berlin, Germany, (3) Institute of Planetary Research, German Aerospace Center (DLR), Berlin, Germany. 1. Introduction surfac