Client Intake Form

General Client Information for Enrollment

We understand that sharing personal information can be sensitive, and we want to assure you that we are committed to protecting your privacy and complying with the Protection of Personal Information (POPI) Act. All information collected is strictly for the purpose of providing you with the best possible care. Your information will be handled confidentially and securely in accordance with POPI regulations. Please provide us with full details to ensure accurate care planning. Omission of critical information may result in inadequate care planning, which could potentially compromise your health and increase any potential risks. Please bring your ID/Passport, proof of address, latest payslip and 3 months bank statement. Thank you for trusting us with your healthcare needs.
Where is your appointment*
Patient Name*

TitleFirst NameMiddle NameLast Name
Preferred Name*
ID number or passport
Please use SA ID
Cell Phone*

Area CodePhone Number
Patient E-Mail*
Patient Birth Date*

MonthDayYear
How did you hear about our office?*

Google SearchFacebookInstagramTik TokReferral
Please check your preferred method of contact for appointment confirmation:*

E-MAILCELL PHONEWORK PHONEHOME PHONE
Are you currently a member of a Medical Aid*

YesNo
Medical Aid - Primary
Member Name
Relationship to Patient
Member DOB
Membership number
Insurance Company Name
Nearest relative not living with you:
Name*
Relationship*
Phone*

Area CodePhone Number
Their address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation*
Are you currently under the care of a healthcare professional?*

YesNo
If yes, please give practice details
What are your current combined monthly household income (this is for market reseach only)

Below R10 000/monthR10 000 - R20 000/monthR21 000 - R35 000/monthR36 000 - R49 000/monthAbove R50 000/month
What is the reason for your visit?*

I want to confirm pregnancyI want to book for antenatal careI am pregnant and I have other problemsRoutine gynae check and Pap smearI have a gynecological problem e.g., fertility issues, fibroids, heavy periodsI want to explore contraception and birth control optionsOther
Do you have you any of the following

DiabetesHIVTBKidney diseaseHeart diseaseThyroidHigh blood pressureHigh body mass(>100 kg)AnaemiaSeizuresBlood disordersCancerDepressionSocial traumaVenous thrombosisOther
Have you had any of the following procedures or conditions

Caesarean sectionMyomectomy (removal of fibroids)Cervical surgery e.g., for treatment of abnormal Pap smearPrevious stillborn babyPregnancy related high blood pressure or diabetesHeart surgeryOther
State any allergies you have
If "other", please give details below
Pre-booking checklist
Signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

General Client Information for Enrollment

Medical Aid - Primary

Nearest relative not living with you: