Patient Comfort IUD Authorisation Request

Submit your Comfort IUD Authorisation Request.

Book your IUD with West Med.

Date

Patient's Surname

Patient's Full Name

Patient's ID Number / Passport

Patient's Date of Birth

Patient's Home Address

Patient's Email Address

Patient's Cell Number

Patient's Work Number

Name & Address of Employer

Next-of-kin Name and Contact No.

Type of IUD (Intra Uterine Device) Requested

Consultation Fee Acceptance

All consultations of patients without a medical aid and available benefits are payable on the day of visit, an admission fee of R600 is payable to the medical centre, balance of your treatment and bill will be payable on discharge.

Medical Scheme

Medical Scheme Plan

Patient Dependant Code

How long has the patient been on this plan type/scheme?

Consent Acceptance

I hereby agree to all the terms and conditions as stipulated above and below.