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    Dear patient,

    Welcome to the practice of Dr Ean Smit, Dr Izolda Heydenrych and their team. To enable us to open a new patient folder, or to update the information we have on file for you, please complete the following form.

    I certify that:

    • The information I am about to enter is true and correct.
    • I hereby consent to the processing of my personal information contemplated in the Protection Personal Information Act No 4 of 2013, by Dr Ean Smit and Dr Izolda Heydenrych and the practice staff.
    • By proceeding, I consent for the office to communicate with me regarding my appointments.

    Patient Information:

    Patient Date of Birth

    Person responsible for the account:

    Kindly take note that this practice is a private practice and payment needs to happen on the day. I take full responsibility to pay for consultations and services rendered to myself and / or my dependents.

    I understand that CDC has strict regulations in place to limit the spread of Covid-19.

    It is of utmost importance that you do not present with the following:

    • Cold of Flu symptoms
    • Temperature of above 37.5
    • Loss of smell and taste
    • Were in contact with anyone who tested positive during the past 14 days

    Covid-19 Protocol:

    • Please arrive for your appointment exactly on time.
    • Parking is available in front of our building.
    • Please notify us of your arrival.
    • Kindly wear your own face mask.
    • Notify us should you test positive in the next 7 days after visiting us.
    I hereby accept CDC’s Covid-19 regulations

    View our privacy policy here

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