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Patient information & Consent

Personal Details

Birthday
Year
Month
Day
Multi-line address

Medical Aid Details

(Please get authorization from your medical aid, NA if private patient)

Medical information

Are you allergic to any food or medication?
Yes
No
Please select all conditions relevant to you:
Do you smoke or make use of tobacco products?
Yes
No
Are you experiencing any of the following?
Have you seen any of the following in the passed 6 months?
Preferred Appointment time (Subject to availability)
Time
HoursMinutes

TERMS & CONDITIONS- CONSENT

TERMS & CONDITIONS- CLINIC ATTENDANCE

TERMS & CONDITIONS- PAYMENTS

FEES

TERMS & CONDITIONS- POPI ACT

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+27 63 321 9586

Panorama Healthcare Center,

60 Hennie winterbach Street

Panorama, Cape Town

Contact Us

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