Ampath Genetics Clinic
167 Witch Hazel Avenue, Highveld Park, Centurion, 0159
geneticsclinic@ampath.co.za
www.ampath.co.za
+27 (012) 678 0645
Request an appointment
Your Full Name:
*
First Name
Last Name
Phone Number
*
E-mail:
*
example@example.com
Who is the appointment for?
*
Please Select
Yourself
Your child
Someone else
Patient details (if appointment is not for yourself):
First Name
Last Name
Patient's date of birth:
*
-
Month
-
Day
Year
Date
Where does the patient currently stay?
Please Select
Eastern Cape
Free State
Gauteng
Limpopo
Northern Cape
North West
Mpumalanga
Western Cape
Other
Reason for appointment:
*
Please Select
Preconception counselling
Prenatal
Cancer genetics
Adult genetic condition
Paediatric genetic condition
Other
Please provide the provisional diagnosis / main problem:
Referring medical practitioner:
Not essential for appointments with a genetic counsellor.
Do you need to see a medical geneticist or genetic counsellor:
Please Select
Genetic counsellor
Medical Geneticist
I don't know
Would you prefer an in person or virtual appointment:
Please Select
In person
Virtual
Note virtual appointments are not possible when the patient requires a clinical examination.
Any additional comments or questions:
Submit
Should be Empty: