Web Page

Step 1 of 6

Personal Information

Your basic details help us create your profile and keep your records accurate.

```

Full Name & Identity

First Name *

Last Name *

Date of Birth *

Gender *

ID / Passport No.

Contact Details

Cell Phone *

Alternative Phone

Email Address *

Preferred Contact Method

📞 Phone Call

💬 SMS / WhatsApp

📧 Email

Home Address

Street Address *

Suburb / Area *

Postal Code

City / Town *

Province *

Emergency Contact

Full Name *

Relationship *

Phone Number *

```

Step 2 of 6

Medical History

This information helps our practitioners understand your health background and provide safe, appropriate care.

```

All medical information is kept strictly confidential and protected under POPIA. It is shared only with your assigned practitioner.

Referring Physician / Doctor

Doctor / Specialist Name

Practice / Hospital

Doctor's Contact Number

Condition & Diagnosis

Primary Diagnosis / Reason for Referral *

Additional details about your condition

Date of Diagnosis / Injury / Amputation

Affected Limb / Area *

Past Orthotics / Prosthetics Use

Have you used an orthotic or prosthetic device before? *

Yes

No, first time

If yes — describe previous device(s) and how they worked for you

General Health

Current Medications

Known Allergies (materials, medications, etc.)

Height (cm)

Weight (kg)

```

Step 3 of 6

Device & Care Needs

Tell us what you need so we can match you with the right specialist and device options.

```

Urgency & Timeline

How urgently do you need this device / service? *

🔴 Urgent – within days

🟡 Soon – within 2–4 weeks

🟢 Flexible – no rush

```

Step 4 of 6

Payment & Medical Aid

Select how you will cover the cost of your care. We work with most major medical aids and offer flexible payment options.

```

Payment Method *

Medical Aid

Cash / EFT

Credit / Debit Card

COIDA / Workmen's Comp

Road Accident Fund (RAF)

Instalment Plan

Medical Aid Details

Medical Aid Scheme *

Medical Aid Plan / Option

Membership Number *

Dependant Code (if applicable) Leave blank if you are the main member

Main Member Name (if different)

Do you need pre-authorisation assistance?

Yes, please help me

No, I'll handle it

Already pre-authorised

```

Step 5 of 6

Appointment Preferences

Let us know how and when you'd like to be seen.

```

Consultation Type *

I'll come to your office

Visit our clinic for a full assessment and fitting in our equipped workspace.

Home / facility visit

We come to you — ideal for patients with limited mobility or transport challenges.

Virtual / Telehealth consult

Initial consultation via video call to assess needs before an in-person visit.

Hospital bedside visit

Our practitioner comes to you in your current hospital or rehabilitation centre.

Preferred Schedule

Preferred Appointment Date

Preferred Time

Additional Needs & Accessibility

I need a language interpreter

We can arrange communication support in your preferred language

I require wheelchair-accessible facilities

We will confirm that your visit location is fully accessible

I will be bringing a caregiver / family member

Please let us know so we can accommodate them

I need transport assistance

We can help arrange transport support where available

```

Step 6 of 6

Consent & Declaration

Please review and agree to the following before submitting your form.

```

Consent Declarations

I consent to assessment and treatment *

I authorise the ProsthetiLink practitioner to assess and treat my condition.

I consent to sharing my information *

My medical information may be shared with my assigned practitioner and, where required, my medical aid or referring doctor.

I consent to medical aid billing *

ProsthetiLink may submit claims to my medical aid on my behalf. I accept responsibility for any shortfall payments.

I consent to being contacted for feedback

ProsthetiLink may follow up with me about my experience and care satisfaction. (Optional)

I confirm all information is accurate *

I declare that all information provided in this form is true and correct to the best of my knowledge.

Signature *

Please sign in the box below using your mouse, stylus, or finger on touchscreen.

Sign here

```

Patient Intake Form

Personal Information

Medical History

Device & Care Needs

Payment & Medical Aid

Appointment Preferences

I'll come to your office

Home / facility visit

Virtual / Telehealth consult

Hospital bedside visit

Consent & Declaration

Form Submitted!