Patient Information Form

Download and complete the printable patient information form and email it to info@winelandsradiology.co.za or fill out the online patient information form below.

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"*" indicates required fields

Branch you will be visiting

Select Imaging Service

Patient Details

Last Name (Surname)*

First Name*

Middle Initials

Title

Gender

Male

Female

Date Of Birth*

Email

Home Phone No.

Cell Phone No.

Medical Aid Details

Medical Aid Name

Medical Aid Plan

Select your plan

Hospital plan

Full cover

Medical Aid Number

Patient Dependent Code

WCA Date of injury

Main Member/Person responsible for payment

Patient Relationship to Main Member

Last Name (Surname)

First Name

Middle Initials

Title

Gender

Male

Female

Date of birth

Email

Home Phone No.

Cell Phone No.

Postal Address

Postal Code

Home Address

Postal Code

Relative or Friend

Last Name (Surname)

First Name

Phone No.

Relationship

Employer (Work) Details

Name

Branch

Contact Person

Phone No.

Business Address

Postal Code

Referring Doctor

Name

Phone No.

Pregnant Ladies

Are you pregnant?

Yes

No

Once you have submitted your request, one of our booking clerks will contact you.

Patient Information Form

Patient Details

Medical Aid Details

Main Member/Person responsible for payment

Relative or Friend

Employer (Work) Details

Referring Doctor

Pregnant Ladies

Procedures

Branches

Bookings