Patient Particulars

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    Emergency Contact 2

    Medical Details

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    Banking Details

    Annual Subscription

    The ANNUAL SUBSCRIPTION is payable ONLY from the SECOND YEAR of ownership. There is no charge for the first year. Please complete the authorisation below as this obviates the need for us to send accounts. If you do not operate a bank account please call us at 0861 115 178 to make alternate arrangements and enable us to activate your bracelet.

    I hereby authorise ELIXIR to draw against my/our account with the under mentioned bank (or any other bank or branch to which I/we may transfer my/our account) the sum of

    R 100 RAND --- (2020)

    Being payment of my annual subscription only commencing 1 year AFTER the date of purchasing a bracelet and continuing until termination by me/us by giving you thirty days’ notice in writing. In the event of an increase in this amount in excess of 10% per annum, I must be advised by ELIXIR, prior to such withdrawal. All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally. If this debit order is dishonoured for any reason, ELIXIR is authorised to resubmit it for payment until such time as it is honoured.