Information for Dr. Consultation Request
For Consultations & Prescriptions. R200 for telephonic Dr. consultation. Unfortunately, no Medical aid excepted, this is a private service. EFT Payments ONLY.
Names
*
Mr.
Mrs.
Miss.
Dr.
Title
First Name
Last Name
ID Number
Phone Number:
*
-
Contact
Number
E-mail
Reason for Phone Consultation:
*
Short Description
Preferred method to receive Script:
Email
Whatsapp
Send to Pharmacy
Pharmacy Number
-
Area Code
Phone Number
Pharmacy Email
example@example.com
Submit Form
Should be Empty: