Application Process

In order to offer you the service of Procedural Sedation and Analgesia we require some detailed information from you. The application form below will guide you through the following four steps:

Patient Information
General Information about the patient.
Account Information
Detailed information of the person responsible for the payment of the account as well as Medical Aid information.
Medical History Questionnaire
A questionnaire where we can determine the patience health (current and past conditions as well as allergies)
Consent Agreement
After we have received the three online form above we will supply you with a quotation and a consent form. By signing this form you will agree to the following:
- Give consent to perform the procedure
- Agree that all provided information is correct
- Acknowledge that you have read and understood all instructions provided.
- Agree to the quotation

Should you prefer not to use the online application please download the application form in PDF format, fill it in and email it back to us.

Download Application Form (PDF)

Existing Clients

If you are an existing client (who has used our service in the past six months), please use this abridged application form. We will then contact you with a new consent agreement and quotation.

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Online Application

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