Patient Information

PATIENT INFORMATION

Name *

First

Last

Phone *

Alternative Contact Number

Email Address *

ID Number *

Date of Birth *

Patient Information

REFERRING DOCTOR & PROCEDURE INFORMATION

Name of Referring Doctor *

Address Main Information

Procedure

MEDICAL AID INFORMATION

Are you a member of a medical aid scheme?

Medical Aid Information *

File Upload *

Click or drag files to this area to upload. You can upload up to 3 files.

Please attach a copy of your Identity Document, Medical Aid Card & a fully completed referral form. Max. file size: 3MB

How would you like to be contacted?

Note

Note:

Details of your booked procedure will be communicated to you during our Office Hours (Monday to Friday 7.30am to 4.30pm)

Consent *

POPIA Document

Click the link below to view the POPIA document:

Contact Central Bookings

If you are unable to complete the above form, kindly contact our central bookings department on central.bookings@lakesmit.co.za or 0800 577 577 to make your booking.