Bookings

Available Services

All consults includes, medical certificates, prescription and or referrals

NB: Medical aids accepted

General Consultation

R300

Acne Consultation (Includes Prescription, medical certificate and or referrals)

initial consult (R500)
Follow-up (R300)

Weight Loss Consultation

initial consult (R500)
Follow-up (R300)

Mental Health Consultation

initial consult (R500)
Follow-up (R300)

Select Appointment Date

What time of day would you prefere for your appointment

consultations are 30 minutes

Morning
(08:00-11:00)

Midday
(11:00-13:00)

Afternoon
(13:00-17:00)

Evening
(17:00-18:00)

Sunday
(15:00-18:00)

Are you a new or an Existing Client

Existing Client

New Client

Who is this Apointmet for

Adult

Child

Patients Name and Surname: ID Number: whatsapp Phone number: Reason for consult:

Child's Name and Surname: Parent ID Number: Parent whatsapp Phone number: Reason for consult:

Patients Email: Patients Name: Patients Surname:

Gender:

Male Female

Marital Status:

Single Married
ID/Passport: Patients Age: Patients whatsapp Number: suburb,town or city: Allergies: Chronic Illnesses: Current Medication: Reason for consult:

Parent Email: Child's Name: Child's Surname:

Gender:

Male Female
Parent ID/Passport: Child's Age: Child's Date of Birth: Parents whatsapp Number: Residential (suburb,town or city): Child's Allergies: Child's Chronic Illnesses: Child's Current Medication: Reason for consult:

Preferred Platform:

WhatsApp video call WhatsApp text Telephone call Zoom Other

Consent form

By continuing with this consultation, you acknowledge that:

Only relevant, personal and medical information is collected for your care.
Your information is securely stored and will not be shared without your consent.
You have the right to access, correct, or request deletion of your data at any time.
Strong security measures are in place to protect your information from unauthorized access.

For more information on how we handle your data, please refer to our Privacy Policy.

Please confirm your understanding and consent:

I have read and understood the information above and I consent to the telemedicine consultation

Payment method

I understand and agree to the consultation fee payable via EFT to account holder: Bless Health Med Standard Bank current account 012528161 Branch code: 051001 and to send proof of payment to whatsapp number 0786012817 before the consultation.
NB: may you please send proof of payment to my WhatsApp or pay via yoco link after submitting form.

Medical Aid Information

I will be using medical aid for the virtual consultation.

Please provide your ID no. to complete consent

Name of Medical aid Medical aid number

Available Services

General Consultation

Acne Consultation (Includes Prescription, medical certificate and or referrals)

Weight Loss Consultation

Mental Health Consultation

Select Appointment Date

What time of day would you prefere for your appointment

Morning(08:00-11:00)

Midday(11:00-13:00)

Afternoon(13:00-17:00)

Evening(17:00-18:00)

Sunday(15:00-18:00)

Are you a new or an Existing Client

Existing Client

New Client

Who is this Apointmet for

Adult

Child

Gender:

Marital Status:

Gender:

Preferred Platform:

Consent form

By continuing with this consultation, you acknowledge that:

Please confirm your understanding and consent:

Payment method

Medical Aid Information

Morning
(08:00-11:00)

Midday
(11:00-13:00)

Afternoon
(13:00-17:00)

Evening
(17:00-18:00)

Sunday
(15:00-18:00)