Appointment call back Request
Please fill out this form to start your care with us. We will ask for information that helps us to prepare for your appointment and validate your medical aid where applicable
Name
*
First Name
Last Name
Which service centre do you want to book your appointment
Woodmead
Busamed Modderfontein Hospital
Pretoria
Virtual
ID or Passport number
*
Date of birth
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Aid
*
Please Select
Discovery Classic
Discovery Comprehensive
Discovery Essential
Keycare
Delta Saver
GEMS
Bonitas
Boncare
Momentum
Kaelo
Cash
Other
Main member
First Name
Last Name
Medical Aid Policy number
Plan
*
If you are cash, enter "Not applicable"
Your dependent number
This is typically found next to your name on the card
If other, please give name of funder and policy details here
Reason for appointment
*
Please Select
Maternity booking, I am pregnant
Routine Gynae check, I have no issues ( e.g. for Pap smear)
Gynae check, I have a gynae problem (fibroids, menstrual, hormonal, infertility other)
Other reason
If other fill out details below
If you chose other, please give details. Include any other important medical or social factors to consider.
Please upload any relevant results or medical reports.
Browse Files
Drag and drop files here
Choose a file
Include referral letters, pathology results and medical reports.
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of
Signature
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