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Online Consultation Form

With Dr. Tinyiko Maphanga

First Name *

Last Name *

Birth Date *

I Am *

MaleFemaleOther

Basic Information

Address *

Phone Number

E-mail *

Occupation *

Main Complaints *

Previous Illness History *

Any surgical History? *

yesno

Allergies *

Appointment

Preferred Date

Preferred Start Time

Appointment Duration

Book any length of time in 30-minute steps — e.g. 1 hour, 1 hour 30 minutes, or 3 hours.

My Services

General Consultation (Virtual)

450.00/ZAR

Prescription Only

300.00/ZAR

General Consultation (In-Person)

600.00/ZAR

Total0.00/ZAR

Pricing is shown for your reference only — no payment is collected online. Our team will confirm your booking and arrange payment with you directly.

Medical Aid Details (Optional)

Medical Aid Provider

Membership Number

Main Member Name

Attachments (Optional)

e.g. referral letters, previous scans, or medical aid documents.

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