New Patient Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First Name: *Last Name: *Gender: *ID Number / Passport Number: *Date of Birth: *Email Address *Contact Number *Home Address: *Referring Doctor (if applicable):Medical Aid Name (if applicable):Medical Number (if applicable):Principle Members Name (if applicable):Principle Members ID number (if applicable):Please note: Not all procedures done in this practice are reimbursed by medical aids. You, not the medical aid, are responsible for the payment of your account to Dr Orrey Derma Clinic immediately after your procedure. *I understand that I am responsible for my account, and not my medical aid.Please note: By submitting this form, I acknowledge that I have read and understood Derma Clinic's Privacy Policy and consent to the collection and use of my personal information as outlined in the policy. *I accept the privacy policySubmit
