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:
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First Name
Last Name
Phone Number
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E-mail:
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Who is the appointment for?
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Yourself
Your child
Someone else
Patient details (if appointment is not for yourself):
First Name
Last Name
Patient's date of birth:
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Day
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Date
Where does the patient currently stay?
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Eastern Cape
Free State
Gauteng
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Reason for appointment:
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Preconception counselling
Prenatal
Cancer genetics
Adult genetic condition
Paediatric genetic condition
Other
Please provide the provisional diagnosis / main problem:
Referring medical practitioner:
Please provide if available but not required.
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:
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In person
Virtual
Note virtual appointments are not possible when the patient requires a clinical examination.
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