PLEASE NOTE: WE DO NOT ACCEPT RESPONSIBILITY FOR THE LOSS OF VALUABLES. LET WEL: ONS AANVAAR NIE VERANTWOORDELIKHEID VIR VERLIES VAN WAARDEVOLLE ITEMS NIE.

I hereby accept full responsibility for the account and acknowledge that I have read and accept the terms and conditions as printed on the reverse side of this document. Ek aanvaar voile verantwoordelikheid vir die rekening en erken dat ek die voorwaardes soos op keersy van hierdie dokument gelees en aanvaar het.

TERMS AND CONDITIONS I hereby declare and warrant that: The information provided is true and correct. • I undertake and promise, notwithstanding any Medical Aid Society or other organisation's undertakings, to pay the account of AR Diagnostics immediately on receipt of the statement. • I agree to pay all and/or any costs, fees and or disbursement incurred by AR Diagnostics for the collection of amounts owing by me which may include tracing costs, debt collectors fees and commission as well as attorney fees and disbursements on the scale of attorney and own client. • I grant consent for any injection and/or other administration of any drugs and/or contrast media which may be necessary for the performance of any medical imaging examination. • I hereby authorise AR Diagnostics who are in possession of information concerning my medical diagnosis and treatment, together with my health and personal particulars to disclose such information to my healthcare funder and other healthcare providers. Permission to disclose such information is only for the purpose of treatment and management of my medical condition. I wish to indicate that this consent is given out of my own free will without any undue influence whatsoever. • I understand that AR Diagnostics shall not be liable, directly or indirectly for any loss, damages, costs and/or expenses directly sustained by me as a result of the services rendered by AR Diagnostics and that I hold them harmless against all and/or losses incurred by me in consequence of any claim arising from the services rendered. • By signing this document I confirm that I am aware that the practice may make the X-ray and other digital images taken by the practice, available in a digital electronic form to medical practitioners, including but not restricted to my medical practitioner. • I consent to such X-rays and other images being made available to all such medical practitioners in a digital/electronic form, and I confirm that I am aware that all such digital/electronic images may be printed out and examined by all such medical practitioners • By signing this document, I confirm that I shall be deemed to have read and understood the terms and conditions contained herein and that I am legally bound thereby.