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Dermatology Enquiry Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Have you been referred by another specialist? If so, please specify.
Are you a new or existing patient?
*
New
Existing
Name and Surname
*
Contact Number
*
Email
*
Which doctor would you like to see
Dr. Nicolina Bardou
Dr. Ilsa (Micky) Orrey
I do not mind
At which practice would you like to make your appointment?
Steenberg Rooms
Constantiaberg Rooms
I do not mind
Please specify the urgency of your appointment
The next available appointment
Within the next 1-2 weeks
Within the next 2-4 weeks
Within the next 3 months
Please indicate the purpose of your appointment
Skin Cancer Screening
Mole/Spots/Skin Tags
Sun Damage
Acne/Acne Scarring
Pigmentation
Redness/Rosacea
Rash(s)
General Skin Care
Eczema
Dermatitis
Psoriasis
Hair Loss
Other:
How did you hear about us?
I am already a patient
Facebook
Google
Instagram
LinkedIn
Word of Mouth - Through a Friend
Other
How would you like us to contact you?
Call me
Email me
Submit
Feedback
Aesthetic Enquiry Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Are you a new or existing patient?
New
Exisiting
Name and Surname
*
Contact Number
*
Email
*
Is there a specific aesthetic treatment you want to have done? If yes, which one
Anti-wrinkle injections
Biostimulators (Sculptra/HArmoniCa)
Intense Pulsed Light (IPL) Photofacial
Electrocautery
Platelet-rich Growth treatments
Injectable Skin Quality Enhancement (ISQE) using HA Fillers for face
Hair Filler
Fat Injection
Facial Sculpting
Unsure
Other:
Which skin issues concern you the most (feel free to select as many options as you feel are relevant)?
Sun Spots
Wrinkles and fine lines
Uneven Skin texture
Redness/Rosacea
Acne and/or Acne Scars
Loss of skin elasticity and/or sagging
Pigmentation
Dull Skin
Other / Specify:
Please specify the urgency of your appointment
The next available appointment
Within the next 1-2 weeks
Within the next 2-4 weeks
Within the next 3 months
How did you hear about us?
I am already a patient
Facebook
Google
Instagram
LinkedIn
Word of Mouth - Through a Friend
Other
How would you like us to contact you?
Call me
Email me
Submit
Feedback
Request Prescription
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Please enable JavaScript in your browser to complete this form.
Name and Surname
*
ID Number / Date Of Birth
*
Email Address
*
Mobile Number
*
Please select your doctor:
Dr. Ilsa (Micky) Orrey
Dr. Nicolina Bardou
Dr. Eddy Zitha
Please enter the details of the item you would like the prescription for:
*
Please specify the pharmacy you would like us to send the script to (optional):
Submit
Feedback
Request Statement
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Please enable JavaScript in your browser to complete this form.
Name and Surname
*
ID Number / Date Of Birth
*
Email Address
*
Mobile Number
*
Please specify the date of the appointment for which you're requesting the statement.
*
Please select the doctor you consulted with.
Dr. Ilsa (Micky) Orrey
Dr. Nicolina Bardou
Dr. Eddy Zitha
Which of our rooms did you have your consultation in?
Constantiaberg Rooms
Steenberg Rooms
Submit
Feedback
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