Request an Appointment

Please specify the location at which you would like to be scheduled.*
What would be the preferable appointment time?
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Which date would you prefer to come for the procedure?
Date*
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Referring Physician
Referring physician office telephone number
Diagnosis or reason for study
Type of study requested
Patient Name and Surname
First Last
Patient date of birth
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Medical aid name
Medical aid number
Contact Number of Patient*
Email address*
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You will be contacted by the department within 8 hours if this document is submitted between 8h00 and 15h00, Monday to Friday. If submitted after this time, you will be contacted the morning of the next business day.
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Please specify a date and time that works for you and we will try our utmost to book the closest available time