Online Doctor Appointment Form

Doctor Appointment Request Form

Please complete the form below. We will email you to confirm your appointment
Select Location for Medical*
Practice Address:

Aviation Medical Services

Merlot Health & Baby Clinic

Merlot Park

Merlot Avenue

Table View
Practice Address:

Aviation Medical Services

EPT Aviation Training

Cnr Fortress & Whirlwind Street

Rhodesfield, Kempton Park

Johannesburg
Name

Last NameFirst Name
Date of Birth

YearMonthDay
Phone No

Country CodePhone Number
Cell No

Country CodeCell Number
Email

Confirmation Emailexample@example.com
Application
Class of Medical
Any known medical conditions?
Any restrictions on current Medical
Preferred Appointment Date Western Cape*
Preferred Appointment Date Gauteng*
Should be Empty:

Doctor Appointment Request Form