Booking Form

Booking form

Bookings are valid for up to three days after the selected booking date.

A valid identification document must be presented on arrival, and any proof of medical aid or corporate referral, depending on the selected payment method.

General Details

Payment Type

Please select a Payment Type.

Booking Date

Please enter a Booking Date.

MA Scheme

Please enter a Medical Aid Scheme.

MA Number

Please enter a Medical Aid Number.

Guarantor/Guardian Details

First name

Please enter a First name.

Last name

Please enter a Last name.

Primary Identity #

Please enter a Primary Identity #.

* Local citizens enter ID Number (for EHR linking).
* International travellers enter Passport Number.

Mobile

Please enter a Telephone number.

Please enter an Email address.

Address

Please enter an Address.

Address 2

City

Province

Please select a Province.

Country

Please select a Country.

Zip

Zip code required.

Copy Details to Patient

Patient Details #

First name

Please enter a First name.

Last name

Please enter a Last name.

Primary Identity #

Please enter a Primary Identity #.

* Local citizens enter ID Number (for EHR linking).
* International travellers enter Passport Number.

Alternate Identity # * Local citizens can enter Passport Number, if required for travel.

Gender

Please provide a Gender.

Date of Birth

Please enter a Date of Birth.

Mobile

Copy Address Details

Address

Please enter an Address.

Address 2

City

Province

Please select a Province.

Country

Please select a Country.

Zip

Zip code required.

Dependant Number/Code

Please enter a Dependant Number/Code.

I hereby consent that the above information can be processed for the purposes of testing and related administrative purposes.

I confirm, to the best of my knowledge, that the above information is correct and accurate.

I hereby consent that the above mentioned person(s) remain liable for full cost of any testing performed. Medical aid or insurance claims cannot be guaranteed and remain the persons responsibility for payment.