Please complete your details below. Your information will then be loaded onto our client management and billing systems for processing.
Client Intake Form Acceptance
I, the undersigned, accept full responsibility for my account and to settle any outstanding payments. Moreover, I accept full responsibility to ensure that I have received the necessary invoices for sessions that I have attended.
If my invoices are paid at private rates, I understand that it is my responsibility to make payment on the date of the invoice.
If my invoices are being submitted to medical aid, I understand that it is my responsibility to liaise with my medical aid regarding payments due and keeping up-to-date with my available funds. The estimated time to get a payment from the medical aid is 4-6 weeks from the date that the invoice is submitted. With all rights reserved, Chevon Cawood has the option to use legal methods to secure payment; this may include a collection agency or small claims court, in which case the cost of such measures will be added to the claim. Notices of outstanding accounts will be served to your residential, postal and work addresses.
I understand that Chevon Cawood may suspend therapy until all outstanding accounts are settled in full.
I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Chevon Cawood serve as a courtesy and have no bearing on the confirmation of an appointment.
I understand that that the email address and mobile number provided by me below will be used for all correspondence related to my appointments and invoices. Should I not receive the related invoice within 5 working days after a session (those that are attended or missed), I will be responsible for ensuring that I follow-up and ensure that I do have a copy of the related invoice.
I, the undersigned, accept that any late-coming will shorten the length of my session and I will be charged in full. Sessions cannot run overtime if the client is late.