Private functional-medicine practice — we do not accept medical aid
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✦ New patient registration

Patient intake form

Completing this before your consultation gives our doctors a full picture of your health, so your R450 appointment is spent on you — not paperwork. All information is kept confidential.

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Please note: we do not accept medical aid

Swiss Medica is a private, cash-based practice. Consultations (R450), the R200 script fee and all products are paid directly by you at the time of service. On request we can provide a paid invoice that you may choose to submit to your medical aid yourself, but we cannot guarantee any reimbursement.

1 Your details

2 Emergency contact

3 What brings you to Swiss Medica?

Select any that apply, then tell us more in your own words.

4 Medical history

This is confidential and helps us prescribe safely. Leave a field blank or write “none” if it doesn’t apply.

5 Lifestyle (optional but helpful)

6 Consent & acknowledgement

By submitting, your details are sent securely to our clinical team. We’ll be in touch to confirm your consultation. Prefer not to fill this in online? Call us on +27 61 167 0260. Please don’t send detailed medical history over WhatsApp — this form keeps it confidential.

Swiss Medica is a private, cash-based practice and does not accept medical aid. Peptides are prescribed as part of a medical consultation and dispensed by a SAHPRA-licensed compounding pharmacy. Information on this website is for general education and does not replace personalised medical advice.