EmailMe Form - Registration Form

Please complete this form in as much detail as possible. You only have to complete it once to register with us. This form may be completed in English or Afrikaans. Each new patient must complete this form once before we can help you. Please keep your details up to date - you may use the relevant fields on this form to update any details. Complete only the field relevant to you. Medical Aid patients must complete the area between ***'s and other patients can skip it.

Your full names *

Your surname *

Your ID/Passport number *

Your email address *

Your occupation and place of work

Method of payment
(Medical Aid - please complete the next 8 questions / If using your credit card or EFT/Deposit - go directly to the question after the area between **'s and make your payment by following the guides on the Website
********************* *

Medical Aid name

Medical aid Plan (eg comprehensive, etc)

Medical aid Option (eg classic, saver, coastal, etc)

Membership number

Main member's name (or initials) and surname EXACTLY as it appears on the medical aid card

Main member's ID number or date of birth if not a SA citizen

Your (patient's) name EXACTLY as it appears on the medical aid card

Your dependant code (please contact your medical aid if not sure)
*******************************************

Name and describe any chronic conditions that you suffer from or have been diagnosed with previously

Name and describe any surgery/operations you had

List any allergies you have (for medication or any other substance)

Smoking, using drugs or alcohol - how many and how regular

Any genetic disorders or infections in close relatives (if not sure, list all diseases in close relatives)

Please list all medication (prescription and supplements + natural products) that you use (include name, dosage and how you take it)

Any additional information you wish to submit regarding your health/medical history

Optional - upload full body image of yourself (body type often help with the diagnosis)

Optional - upload any documents (eg medical reports, test results, etc)

Do you agree to the terms and conditions for using this service and did you read the disclaimer

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Thank you for taking the time to register with us. Please click on the button and submit this form and then move on to complete the second form for the actual consultation.