Please use the form below to request an appointment and our friendly team will be in touch to confirm availability. Your Details MrMissMrsMsDrProfOther Title First Name Surname Phone Email Do you have a referral? If you have a referral, please take a photograph using your mobile phone or attach a scanned copy of this. Attach your referral Date of birth (dd/mm/yyyy) Examination request Preferred clinic Covid-19 Yes No Are you under any SA Health directive to self-isolate or quarantine? Yes No Are you awaiting Covid-19 test results? Yes No Do you have any Covid-19 symptoms? Submit