Patient Information Form | Dr FS Hlatshwayo Medical Clinic

This form collects only the essential information we need ahead of your visit. A more detailed medical history will be completed with you in person, in confidence, by our clinical team.

Personal Details

Full Name *

Date of Birth *

ID / Passport Number *

Gender

Phone Number *

Email Address

Home Address

Medical Aid Details (if applicable)

Scheme Name

Plan / Option

Membership Number

Main Member Name (if different)

Emergency Contact

Contact Name *

Relationship to You

Contact Phone *

Brief Medical History

Known Allergies

Current Chronic Conditions

Current Medication

Reason for Visit

I confirm that the information provided above is accurate to the best of my knowledge. *

I consent to Dr FS Hlatshwayo Medical Clinic collecting and processing my personal and health information, in line with POPIA, solely for the purpose of providing my medical care. View our Privacy Policy. *

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Why Complete This Early?

Submitting your details online ahead of time means less paperwork and a faster check-in at reception.

Not booked yet? Book your appointment first, then complete this form.