Request an appointment

Please use the form below to request an appointment and our friendly team will be in touch to confirm availability.

Your Details

Title

First Name

Surname

Phone

If you have a referral, please take a photograph using your mobile phone or attach a scanned copy of this.

Attach your referral

Date of birth (dd/mm/yyyy)

Examination request

Preferred clinic

Yes

Are you under any SA Health directive to self-isolate or quarantine?

Yes

Are you awaiting Covid-19 test results?

Yes

Do you have any Covid-19 symptoms?

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