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1 PATIENT DETAILS
Mr    Mrs    Miss    
Surname First Names
Marital Status  
Date of Birth ID Number
Occupation Home Language
Tel.(H) Tel.(B)
Cell E-mail

2 Person responsible for account DETAILS
Mr    Mrs    Miss      
Surname First Names  
ID Number      
Home Address   Code
Postal Address   Code
Employer      
Work Address   Code
Tel.(H) Tel.(B)  
Cell E-mail

 

3 MEDICAL AID
Name Number  

Member's Name

ID No  
Tel.(H) Tel.(B)  
Cell      

 

4 NEAREST FAMILY/FRIEND
Name Relationship    
Address   Code
Tel.(H) Tel.(B)    
Cell        

 

5 REFERRED BY
Name Tel.

 

6 FAMILY DETAILS
Names Date of Birth Allergies Other

Appointment Disclaimer

While we make every effort to honor all appointments made on our website, appointments made within (12) twelve hours of the actual appointment time may conflict with other appointments already made or other events, so we can not guarantee those times. To avoid this possibility, please try and schedule your appointments at least 24 hours in advanced.

Late arrivals of 10 minutes or more run the risk of loosing their appointment time. So please make every effort to be on time to avoid loosing yours.

Thank you in advance for your understanding and for your continued patronage.

Namibia Aesthetics and General Medical Practice, CMC Building,No1 Merensky Str, Snyman Circle.
Tel: +264 61 402 807/809


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