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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Patient Information

First Name

Last Name

Date of Birth

Has your Account Information changed since your last procedure?

YESNO

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?

YESNO

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

Online Application

[[[["field2","contains","Female"]],[["show_fields","field52"]],"and"]]

Patient Information

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

FemaleMale

Height (cm)

Weight (Kg)

Pregnancy

	Yes	No
Are you, or is there any possibility that you might be pregnant?

Cardiovascular disease

	Yes	No
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

	Yes	No
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

	Yes	No
Have you had thrombosis, embolism in the legs or lung?

If the answer is "yes", please provide a detailed explanation

Blood Disorders

	Yes	No
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

	Yes	No
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

Latest blood sugar reading?

If any answer is "yes" please provide a detailed explanation

Liver

	Yes	No
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

	Yes	No
Do you suffer from kidney disease / renal failure?

If answer is "yes" please provide a detailed explanation

Muscular Disorder

	Yes	No
Do you suffer from myopathy, dystrophy or progressive weakness?

If answer is "yes" please provide a detailed explanation

If any answer is "yes" please provide a detailed explanation

Stomach problems

	Yes	No
Do you suffer from indigestion, heartburn, hernia or ulcers?

If the answer is "yes" please provide a detailed explanation

Hereditary diseases

	Yes	No
Are there any hereditary diseases in your family?

If the answer is "yes" please provide a detailed explanation

Hospitalisations and Operations

	Yes	No
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

	Yes	No
Do you suffer from allergies (especially and allergy to medication)?

If the answer is "yes" please provide a detailed explanation

Medication

	Yes	No
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

	Yes	No
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

	Yes	No
Do you suffer from any infectious disease (HIV, Hepatitis)?

If answer is "yes", please provide a detailed explanation

Others

	Yes	No
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

	Yes	No
Do you suffer from thyroid problems?
Do you suffer from porphyria or other metabolic disorders?
Do you suffer from diabetes?

	Yes	No
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?