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Dermatology
QuickSpot Consultation
Repeat Script
Find Us

Steenberg – 021 797 4294
Constantiaberg – 021 762 0760

Home
About Us
Aesthetics
Dermatology
QuickSpot Consultation
Repeat Script
Find Us
Work With Us
- Dermatologist
- Employee

Request Statement

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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. Zweli G. Lukhele

Which of our rooms did you have your consultation in?

Constantiaberg Rooms
Steenberg Rooms

Providing skin therapy that is SAFE, EFFECTIVE and AFFORDABLE. Effective treatments and Quick Spot analysis for healthy skin.

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Steenberg:

Suite G6 Steenberg House
Steenberg Office Park
Westlake
Cape Town

021 797 4294

drorrey@dermaclinic.co.za

Constantiaberg

206 Mediclinic Constantiaberg
Burnham Road
Plumstead
Cape Town

021 762 0760

drorrey@drorrey.co.za

Office Hours

Monday to Thursday – 8:30 to 16:30
Friday – 8:30 to 13:00
Saturday to Sunday – Closed

Dermatology Enquiry Form

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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. Ilsa (Micky) Orrey
Dr. Zweli G. Lukhele
Dr. Nicolina Bardou
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

Aesthetic Enquiry Form

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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

Request Prescription

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Name and Surname *

ID Number / Date Of Birth *

Email Address *

Mobile Number *

Please select your doctor:

Dr. Ilsa (Micky) Orrey
Dr. Nicolina Bardou

When last did you see your doctor?

About 1 month ago
About 3 months ago
About 6 months ago
More than a year ago

For ORAL medication (PILLS / CAPS / TABLETS) - specify the NAME of the medication:

For ORAL medication (PILLS / CAPS / TABLETS) - specify the DOSAGE of the medication:

For TOPICAL medication, please specify NAME of medication:

For TOPICAL medication, please specify if:

Cream
Gel
Lotion
Ointment
Spray

How many REPEATS would you like the doctor to issue?

30 days
2 months
3 months
6 months

Is there any additional information you would like to add for the doctor?

Request Statement

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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. Zweli G. Lukhele

Which of our rooms did you have your consultation in?

Constantiaberg Rooms
Steenberg Rooms

Request Call Back

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Name *

First

Last

Contact Number - Please make 100% sure number is correct! *

Email (linked to your account) *

Reason for Call Back *

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