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Dermatology Enquiry Form
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Please enable JavaScript in your browser to complete this form.
Have you been referred by another specialist? If so, please specify.
Are you a new or existing patient?
*
New
Existing
Name and Surname
*
Contact Number
*
Email
*
Which doctor would you like to see
Dr. Nicolina Bardou
Dr. Ilsa (Micky) Orrey
I do not mind
At which practice would you like to make your appointment?
Steenberg Rooms
Constantiaberg Rooms
I do not mind
Please specify the urgency of your appointment
The next available appointment
Within the next 1-2 weeks
Within the next 2-4 weeks
Within the next 3 months
Please indicate the purpose of your appointment
Skin Cancer Screening
Mole/Spots/Skin Tags
Sun Damage
Acne/Acne Scarring
Pigmentation
Redness/Rosacea
Rash(s)
General Skin Care
Eczema
Dermatitis
Psoriasis
Hair Loss
Other:
How did you hear about us?
I am already a patient
Facebook
Google
Instagram
LinkedIn
Word of Mouth - Through a Friend
Other
How would you like us to contact you?
Call me
Email me
Submit
Aesthetic Enquiry Form
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Please enable JavaScript in your browser to complete this form.
Are you a new or existing patient?
New
Exisiting
Name and Surname
*
Contact Number
*
Email
*
Is there a specific aesthetic treatment you want to have done? If yes, which one
Anti-wrinkle injections
Biostimulators (Sculptra/HArmoniCa)
Intense Pulsed Light (IPL) Photofacial
Electrocautery
Platelet-rich Growth treatments
Injectable Skin Quality Enhancement (ISQE) using HA Fillers for face
Hair Filler
Fat Injection
Facial Sculpting
Unsure
Other:
Which skin issues concern you the most (feel free to select as many options as you feel are relevant)?
Sun Spots
Wrinkles and fine lines
Uneven Skin texture
Redness/Rosacea
Acne and/or Acne Scars
Loss of skin elasticity and/or sagging
Pigmentation
Dull Skin
Other / Specify:
Please specify the urgency of your appointment
The next available appointment
Within the next 1-2 weeks
Within the next 2-4 weeks
Within the next 3 months
How did you hear about us?
I am already a patient
Facebook
Google
Instagram
LinkedIn
Word of Mouth - Through a Friend
Other
How would you like us to contact you?
Call me
Email me
Submit
Request Prescription
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Please enable JavaScript in your browser to complete this form.
Name and Surname
*
ID Number / Date Of Birth
*
Email Address
*
Mobile Number
*
Please select your doctor:
Dr. Ilsa (Micky) Orrey
Dr. Nicolina Bardou
When last did you see your doctor?
About 1 month ago
About 3 months ago
About 6 months ago
More than a year ago
For ORAL medication (PILLS / CAPS / TABLETS) - specify the NAME of the medication:
For ORAL medication (PILLS / CAPS / TABLETS) - specify the DOSAGE of the medication:
For TOPICAL medication, please specify NAME of medication:
For TOPICAL medication, please specify if:
Cream
Gel
Lotion
Ointment
Spray
How many REPEATS would you like the doctor to issue?
30 days
2 months
3 months
6 months
Is there any additional information you would like to add for the doctor?
Submit
Request Statement
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Please enable JavaScript in your browser to complete this form.
Name and Surname
*
ID Number / Date Of Birth
*
Email Address
*
Mobile Number
*
Please specify the date of the appointment for which you're requesting the statement.
*
Please select the doctor you consulted with.
Dr. Ilsa (Micky) Orrey
Dr. Nicolina Bardou
Which of our rooms did you have your consultation in?
Constantiaberg Rooms
Steenberg Rooms
Submit
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