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Application Process

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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1
Patient Information
First Name
Last Name
Title
Date of Birth
Has your Account Information changed since your last procedure?
Account Details (person responsible for the account)
First Name
Last Name
ID Number
Home Address
0 /
Postal Address
0 /
Telephone (Home)
Telephone (Office)
Telephone (Mobile)
Emaila valid email
Has your Medical Aid Information changed since your last procedure?
Medical Aid Details (for account purposes only)
Medical Aid Scheme
Medical Aid Plan
Name of Main Member
Medical Aid Number
Patient Dependant Code
Authorisation or Reference Code
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Online Application

[[[["field2","contains","Female"]],[["show_fields","field52"]],"and"]]
1
Patient Information
Title
First Name
Last Name
Date of Birth
Occupation
Language
Account Details (person responsible for the account)
First Name
Last Name
ID Number
Employer
Home Address
0 /
Postal Address
0 /
Telephone (Home)
Telephone (Office)
Telephone (Mobile)
Emaila valid email
Medical Aid Details (for account purposes only)
Medical Aid Scheme
Medical Aid Plan
Name of Main Member
Main Member ID Number
Medical Aid Number
Patient Dependant Code
Authorisation Number
Medical Questionnaire
Age
Sex
Height (cm)
Weight (Kg)
Pregnancy
YesNo
Are you, or is there any possibility that you might be pregnant?
Cardiovascular disease
YesNo
Do you suffer from heart failure, ischemic heart disease e.g. angina, heart attack?
Do you suffer from heart valve lesion, rheumatic fever, congenital heart disease?
Do you suffer from dysrythmia, palpitations (without exertion), blackouts?
Do you become short of breath when lying down or walking on a level surface?
Do you suffer from high blood pressure? If "yes" whats was your last blood pressure reading?
If any answer is "yes", please provide a detailed explanation
Central Nervous System disorders
YesNo
Do you suffer from epilepsy, fits (convulsions), giddiness?
Do you suffer from depression, psychosis?
Have you had a stroke?
Do you suffer from Autism?
Do you suffer from ADHD, Hyperactivity?
If any answer is "yes", please provide a detailed explanation
Blood Clots
YesNo
Have you had thrombosis, embolism in the legs or lung?
If the answer is "yes", please provide a detailed explanation
Blood Disorders
YesNo
Do you suffer from anaemia, sickle cell disorder, thalasaemia, etc.?
Have you had abnormal bleeding associated with previous extractions, surgery or trauma and do you bruise easily?
If any answer is "yes", please provide a detailed explanation
Respiratory
YesNo
Do you smoke? If "yes" how many a day?
Do you snore and or have sleep Apnoea?
Do you suffer from lung disease (e.g. asthma, emphysema, TB)?
Have you had Flu or chest infection in the last 4 weeks?
If any answer is "yes" please provide a detailed explanation
Endocrine disorders
YesNo
Do you suffer from thyroid problems?
Do you suffer from porphyria or other metabolic disorders?
Do you suffer from diabetes?
Latest blood sugar reading?
If any answer is "yes" please provide a detailed explanation
Liver
YesNo
Do you suffer from hepatitis or have a history of jaundice or any other Liver disease?
Do you drink alcohol?
If yes, amount per day/week?
If any answer is "yes" please provide a detailed explanation
Renal
YesNo
Do you suffer from kidney disease / renal failure?
If answer is "yes" please provide a detailed explanation
Muscular Disorder
YesNo
Do you suffer from myopathy, dystrophy or progressive weakness?
If answer is "yes" please provide a detailed explanation
Orthopeadic problems
YesNo
Do you suffer from arthritis?
Do you suffer from lower back problems?
Do you suffer from decreased neck mobility?
do you suffer from decreased mouth opening?
If any answer is "yes" please provide a detailed explanation
Stomach problems
YesNo
Do you suffer from indigestion, heartburn, hernia or ulcers?
If the answer is "yes" please provide a detailed explanation
Hereditary diseases
YesNo
Are there any hereditary diseases in your family?
If the answer is "yes" please provide a detailed explanation
Hospitalisations and Operations
YesNo
Have you ever been admitted to hospital?
If the answer is "yes" please provide a detailed explanation
History of allergy in general, or allergic reactions to medications
YesNo
Do you suffer from allergies (especially and allergy to medication)?
If the answer is "yes" please provide a detailed explanation
Medication
YesNo
Do you take any regular medication (drugs), including herbal and recreational drugs?
If the answer is "yes", please provide a detailed explanation
0 /
Anaesthesia / Sedation
YesNo
Have you ever had any adverse or unpleasant reaction to anaesthesia or sedation?
Have you had a failed sedation (cancelled due to difficulty) ?
If any answer "yes", please provide a detailed explanation
Infectious Disease
YesNo
Do you suffer from any infectious disease (HIV, Hepatitis)?
If answer is "yes", please provide a detailed explanation
Others
YesNo
Is there anything you would like to discuss but prefer not to submit here?

If the answer is "yes", please contact your seditionist and discuss this with him or her before the date of your procedure.

Designated Driver who will take patient home
Name of driver
Phone of driver
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