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Online Consultation Cancellation Form
Please supply us with your details so that your consultation may be cancelled.
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* Indicates required question
Surname
*
Your answer
First Name/s
*
Your answer
SA ID Number
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Cellphone number
*
Your answer
Address
*
Your answer
Medical Aid Number
*
Your answer
Medical Aid Name
*
Your answer
Medical Aid Plan
Your answer
Please select:
*
Cancelllation with no charge.
Cancellation, please invoice my medical scheme as appropriate.
Required
Reason for cancellation:
Your answer
Submit
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