DR ZINZI LIMBA'S

Cost Insurance Form

    I (X) agree that I will be liable to pay this outstanding amount if incurred.

    Enter Name

    I am hereby responsible to pay any outstanding amount.

    I do understand that should I not pay on the given or arranged date, that further action will be taken against me by Dr BPZ Limba, PR NO: 0775517 based at Life Mercantile Hospital.

    Parties Present:

    Name

    Surname

    Signature

    Agreement Date

    Reasons for not being able to pay: Not applicable

    Banking Details (EFT)

    Bank: Investec Bank

    Acc Name: Dr Zinzi Limba

    Acc No: 10012493590

    Ref: (your name and surname)

    Banking Details (CASH)

    Bank: ABSA

    Acc Name: Investec Bank Dr Zinzi Limba Inc

    Acc No: 01043960306

    Ref: 10012493490 (your name and surname)

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