Oneness Quick Clinic

1

What number tag was placed on your windscreen? * This field is required.Only register if you are on site. THIS IS NOT AN APPOINTMENT.

2

Full Name* This field is required.Please ensure the name entered matches the name in your Passport or Government Issued ID.

3

What would you like to get done today?* This field is required.Please select a service Rapid COVID & FLU A/B - $10,000 Rapid HIV - $7,000 Rapid Syphilis - $7,000 (PRICE WITHOUT CONSULTATION) Health Insurance Accepted for Doctor Visits/Consultations

Rapid COVID + Flu A/B Testing

Doctor Consultation ($8,000)

Laboratory Services

Rapid HIV

Rapid Syphillis

Other

4

DISCLAIMER

By pressing next you are acknowledging that you understand the prices and how we will bill you. A medical consultation fee is $8,000. If you require procedures in addition to the consultation then the price will be $8,000 + the procedure fee.

ALL TESTS DONE WITHOUT A CONSULTATION ATTRACT A SERVICE CHARGE OF $3,500

5

Have you been here since 2025* This field is required.Exciting News for Our Valued Patients! We’re enhancing your healthcare experience! 🌟 We are now using Juvonno software to provide you with instant access to your medical records—anytime, anywhere. And the best part? It’s completely FREE!

Yes

No

6

Email* This field is required.Please ensure the email is typed correctly before submitting to ensure your medical information is sent to the correct address.

example@example.com

7

Date of Birth* This field is required.Month/Date/Year

Date

8

Gender* This field is required.

Male

Female

9

Today's Date

Date

10

Phone Number* This field is required.

11

Treatment Authorization Form* This field is required.Patient Treatment: Informed Consent Please carefully read the following Informed Consent: Patient’s Name: {fullName} D.O.B : {dateOf} a. I, {fullName}, hereby give consent to Oneness Drive Thru Health Centre and their medical team to handle my / the patient’s confidential medical information and provide the necessary care, testing and treatment for the complaint/ailment for which I / the patient have presented. b. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical services rendered. C. I, {fullName}, hereby give consent to Oneness Drive Thru Health Centre and their medical team to collect my / the patient’s blood sample to facilitate the laboratory test(s) for which I / the patient have requested. D. I understand that, the email address provided may be used to send me special alerts and more.

I have read, understood and agree to the terms and conditions stated above and provide consent to Oneness Drive Thru Health Centre to render medical services .