Online Intake

Book a Consultation

Please fill out your intake information below. Once submitted, you will be connected directly with Dr. Kauthar on WhatsApp to confirm your appointment date and time.

Reason for Visit

Select the type of treatment you are booking, then describe your main complaint.

Treatment Type

Main Complaint

Patient Information

Please complete all fields below so we can prepare your patient file.

Full Name & Surname

Gender

Date of Birth

Contact Details

How can we reach the patient directly?

Mobile Number

Emergency Contact Full Name

Emergency Contact Mobile

Final Consent

Please review the following terms before confirming your booking.

Payment Methods

We accept Cash or EFT payments.

BankCapitec bank

Account Number1742416215

Branch Code470010

I agree to the Terms & Conditions and understand how my data will be processed in accordance with the Privacy Policy.