BOOKING REQUEST FORM

Drs Kauffman and Partners Inc takes the privacy of persons seriously, and is therefore committed to ensuring that personal information in its possession or under its control is secure.

PATIENT INFORMATION

First Name *

Last Name *

Contact Number *

Alternative Contact Number *

Email *

Date of birth *

ID Number *

REFERRING DOCTOR & PROCEDURE INFORMATION

Name of Referring Doctor *

Select a Procedure

MEDICAL AID INFORMATION

Are you a member of a medical financial scheme?

Medical Aid Information *

Yes

No

Please attach a copy of your ID *

Please attach a copy of your Medical Aid Card

Please attach a copy of your Referal Letter *

How would you like to be contacted? *

Cellphone

Email

Concent *

I agree to the Privacy Policy

If you are unable to complete the above form, kindly contact our bookings department on [email protected] or your nearest branch to make your booking

Netcare St. Annes Hospital

320 JABU NDLOVU ST, pietermaritzburg

LIFE HILTON HOSPITAL

c/o Hilton ave & Monzali Drive, Hilton

Hilton Health&wellness centre

Next to Life Hilton Hospital

Life Diagnostics HOWICK

93 Main Street, Howick

Lenmed Private Hospital 107 Main Street Howick

Dr Kauffman & partners inc.

Radiology done right

#TEAMKAUFFMAN