Patient Intake Form

Please complete this form before your visit. Your information is kept strictly confidential.

POPIA

POPIA Compliant

Protected under the Protection of Personal Information Act

Personal Information

First Name *

Last Name *

SA ID Number (13 digits)

Enter your 13-digit SA ID number to auto-fill date of birth and gender below. Leave blank if using a passport.

Date of Birth *

Gender

Contact Details

Phone Number *

Email Address

Residential Address

Emergency Contact

Full Name

Phone

Relationship

Today's Visit

Reason for Visit

Current Symptoms

Insurance / Medical Aid

Funding Type

Medical Aid Provider

Member / Policy Number

Digital Consent & POPIA Declaration

Please read and tick each item before submitting

In accordance with the Protection of Personal Information Act (POPIA), Act 4 of 2013, this practice is required to inform you that:

Your personal and health information will be collected, stored, and processed for the purpose of providing medical care.
Your information will be kept strictly confidential and will only be accessed by authorised healthcare professionals.
Your data will not be shared with third parties without your explicit consent, except where required by law.
You have the right to access, correct, or request deletion of your information at any time.

I consent to this practice collecting and storing my personal and health information for the purpose of medical treatment.I understand that my information may be shared with other treating healthcare providers directly involved in my care.I confirm that the information I have provided in this form is accurate and complete to the best of my knowledge.I acknowledge that I have been informed of my rights under POPIA and consent to the processing of my personal information as described above.

By submitting this form, you provide your digital consent. This is legally binding under South African law. Your IP address and submission timestamp are recorded for audit purposes.

Digital Signature

By typing your full name below, you confirm that the information provided is accurate and that you agree to the consents ticked above. This serves as your legal digital signature.

Confirming on behalf of: Patient name will appear here

Type your full name to sign

I confirm my digital signature above. By ticking this box I acknowledge this submission constitutes my legal signature and consent.