Request an Appointment

Phone
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Please specify the location at which you would like to be scheduled.*
What would be the preferable appointment time?
(Some appointment times may not be available)
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Which date would you prefer to come for the procedure?
Date*
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
Medical aid name
Medical aid number
Contact Number of Patient*
Email address*
Comments
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