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 POPIA 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 forvyour appointment. 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
What is the reason for your visit?

Other
Are you currently a member of a Medical Aid
Medical Aid - Primary
Main member name:
Relationship to Patient
Member DOB
Membership number
Medical aid plan:
Dependant code:
Insurance Company Name
Nearest relative not living with you:
Name
Relationship
Their Phone

Area CodePhone Number
What are your current combined monthly household income (this is for market reseach only)
Do you have you any of the following

Other
State any allergies you have
none
If "other", please give details below
Are you pregnant?
Your weight (kg)
Your height (metres)
type with a decimal place
Has any of this happened in a PAST pregnancy, or before?
Do you have any ONGOING conditions?
About THIS pregnancy and your situation
Pre-booking checklist
How did you hear about our office?
Please check your preferred method of contact for appointment confirmation:
Permanent Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
WhatsApp communication
Signature
Date

MonthDayYear
Date
Are you currently under the care of a healthcare professional?
Should be Empty: