Kingsbury Hospital
Constantiaberg Mediclinic
Vincent Pallotti Hospital
Appointment
Have an Emergency
 
 		  
Schedule an Appointment

Welcome to our new appointment booking feature where you can make your appointments with us online!

Please note that these appointments are provisional and confirmation thereof are made by us on receipt of the appointment request. You will be confirmed either telephonically or via email.

Please fill in your details below and click "submit"
We will respond to your request as soon as possible.
Patients Details

 		 DETAILS OF MEMBER OR PERSON
RESPONSIBLE FOR ACCOUNT
(Ignore if same as patient details)
       
Surname Surname
Name Name
Title Title
Date of Birth Date of Birth
ID NO ID NO
Home Tel Home Tel
Work Tel Work Tel
Cell Cell
Med Aid/Hosp Plan Employer/Company
Membership Number E-mail
GAP Cover Insurance Account Address
Meds Ins Policy  
Address  
Code
Code Domicilium Citandi
(if other)
Employer    
Home GP GUARANTOR IF PERSON RESPONSIBLE FOR ACCOUNT IS NOT THE MEMBER OF MEDICAL AID OR PATIENT.
Referring Doctor Name
Next of Kin name ID No
Tel Address
Relation  
     
Which doctor would you like to see? Tel No:

Brief Description of Problem
   
Anti-spam Sum of 9 + 1 ?

INTEREST ACCRUES AFTER 30 DAYS.
MEDICAL AIDS ARE REFUNDING DIFFERING AMOUNTS AND OUR FEES MAY BE MORE THAN YOUR MEDICAL AID WILL REFUND YOU
PLEASE DISCUSS THE FEES WITH THE SURGEON AND ASK FOR AN APPROXIMATE QUOTATION

The above details have been completed correctly and accurately.
 
 
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