Booking Form with Calendar

1
How can we help today?* This field is required.Remote consultations take place over WhatsApp/Text/Phone or video call.
Remote ConsultCallOut / Home Visit
2
Remote: Choose a time slot convenient for you.* This field is required.If there's earlier availability, we'll let you know!
3
Call-Out: Choose a time slot convenient for you.* This field is required.Note: Call-Outs currently only available in Cape Town Southern Sub/Atlantic Seaboard/City Bowl
4
Where do we meet you?* This field is required.Your home, office, or somewhere else? Let us know via WhatsApp if there's any special instructions.
Street Address
Street Address Line 2
City
State
Zip Code
South Africa
South Africa
Country
5
Who is the booking for?* This field is required.(Names as they appear on ID or Passport)
First Name
Last Name
6
Email* This field is required.Double check it so that your documents and prescriptions don't get lost in the mail!
example@example.com
7
Phone Number* This field is required.How can we reach you?
Enter a valid cell phone number - preferably one linked to WhatsApp.
8
Feeling under the weather? Or just here for a follow-up?Give us a brief description of how we can help in your consultation - if you feel like it!
How are you, really? ♥️
9
Lastly: Do you have a discount CODE for your first consultation?- this might be from your employer or promotion
leave me blank if not
10
One last thing: Where did you hear about Doxi?
Friends or Family
Google
Social Media
A Pharmacy
Other
Should be Empty: