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:
General Information about the patient.
Detailed information of the person responsible for the payment of the account as well as Medical Aid information.
A questionnaire where we can determine the patience health (current and past conditions as well as allergies)
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:
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.
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.
If the answer is "yes", please contact your seditionist and discuss this with him or her before the date of your procedure.