Beautez Pharmacy Branch*
Date of Birth

Payment Mode(Options : 1. Cash Payment, 2. Medical Aid Payment)
Patient Name*
- Title
- First Name 
- Last Name

Patient Phone Number*

[Area Code] [Phone Number]

Patient Identity Number

Patient Email*

Consulting Doctor(select doctor)
Doctor Email*
Types of Consultation*
- Diagnostic Consultation
- Remote Consultation
- Primary care Consultation
- Mental health support
- Psychoanalytic or Psychodynamic Therapy

Medical History*<Table columns below> must allow multiple records using +

Diagnosis/ Allergies(Text Area) |   Medicines if taken(Teaxt Area) | Still Using(yes/no) | Additional Notes(Text Area)


Resp Patten [text filed]

Spo2 [text field]
blank %. 
Temp in Celcious [ text field ]



Blood Pressure[text field] mmHg
Pulse Rate [text field] bpm
RBS [text field]  %

Additional Medical Notes [Large Text Area]


Phone Number*This field is required.
Area Code, Phone Number


Appointment Date & Time

Please Select
- Consult Doctor Now.
- Book Appointment With a Doctor


Please Select an Appointment Date*This field is required.
31/12/2025

December


2025

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Wednesday, December 31
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07:00
07:30
08:00
08:30
09:00
09:30
10:00
10:30
11:00
11:30


Attach Patient Documents
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Browse Files

Pharmacist Signature*This field is required.

Client Signature*This field is required.

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