LifeAssist Online Booking

Full name and surname of the person attending the appointment

First NameLast Name

Company / Organisation Details

Company Name

Who is making this booking?

Even if you are wanting to book for another person, we will still need to discuss the referral with you at the scheduled appointment time

If you are booking for someone else, please provide your Name and your relationship to them.

Your Name & SurnameRelationship To Attendee

Are you currently located within South Africa or outside the country?

Your Contact number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred contact number (mobile/landline)

Please enter a valid phone number.Format: (000) 000-0000.

Alternative contact number (optional)

If Preferred number is not available please provide an alternative contact numberFormat: (000) 000-0000.

Phone Number

Country CodeArea CodePhone Number

Email (for confirmation and reminders)

example@example.com In order for us to send you a confirmation, we need your email address. Please provide the email address where we can send your booking details

Preferred Language

If Other, please specify

hidden email

What is the main reason for booking?

Appointment : See available appointments. Please select prefered time and date.

Are you (or the person you are booking for) feeling at risk of harming yourself or others right now?

Do you need urgent assistance or immediate crisis support?

IF YES TO ANY OF THE TWO OPTIONS ABOVE :
PLEASE CONTACT OUR NATIONAL SUPPORT CENTER IMMEDIATELY FOR ASSISTANCE - 0800 060 026

Consent & Confidentiality

Please be advised that we keep your personal information in our systems for a minimum of five years. You have the right to access this information in accordance with the Health Professions Act and the Protection of Personal Information Act (POPI). You can also correct your personal details. Our complete data use and privacy guidelines are available on request. Do we have your consent to share your details within our network of affiliates and staff members? If you do not consent, then we can provide you with our services but they may be limited depending on the amount of information that you are willing to provide.
For more information please visist : https://lifeassist.co.za/

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LifeAssist Online Booking

Contact Information