Digital registration

Register before you arrive.

Complete your details online and your file is ready when you walk in. It takes about three minutes.

What happens with your details

Your information is used to create your patient file, schedule your appointment and — where applicable — submit a medical aid claim.
It is stored securely and seen only by authorised PG Health staff. We never sell it or share it for marketing.
You can ask us to correct or delete your details at any time by emailing admin@pghealth.co.za.
Full detail is in our privacy and POPIA notice.

Please do not use this form for an emergency. Phone 011 784 7408 or go to your nearest emergency department.

About you

As it appears on your ID or passport.

TitleFull namePreferred nameID or passport numberUsed for your patient file and medical aid claims only.Date of birthGenderOccupation

How we reach you

EmailContact numberPreferred contact methodStreet addressSuburbCityPostal code

Your visit

Preferred practiceType of careHow did you hear about us?

Emergency contact

Someone we may contact if we cannot reach you.

Contact nameRelationship to youContact number

Medical aid

Leave blank if you are settling the account privately.

SchemePlan or optionMembership numberMain member nameDependant code

Medical background

Share what you are comfortable sharing here — the rest can be discussed in person.

AllergiesChronic conditionsCurrent medicationPrevious surgery or hospital admissionsDo you smoke?Pregnant or breastfeeding?Anything else we should know

Consent

I consent to PG Health Group collecting and storing the information above for the purpose of providing dental, eye, general practice and wellness care, scheduling appointments and submitting medical aid claims where applicable, as described in the privacy notice.

Optional: send me practice updates and appointment reminders. You can opt out at any time.