Telemedicine Appointment Application

1
Beautez Pharmacy Branch* This field is required.
Please Select
Please Select
BTZ001 Beautez Pharmacy Maseru Mall
BTZ002 Beautez Pharmacy Lifestyle Centre
BTZ003 Beautez Pharmacy NRH Mall
BTZ004 Beautez Pharmacy Ha-Foso
BTZ005 NUTRIMED Maseru Mall
2
Date of Birth
Month
Day
Year
3
Payment Mode
Cash Payment
Please Select
Cash Payment
Medical Aid Payment
LOYALAID PAY
4
Select Your Medical Aid
Please Select
Please Select
LOYALAID DIGITAL PAY
METROPOLITAN MEDICAL AID
LIBERTY MEDICAL AID
DISCOVERY MEDICAL AID
VITALITY MEDICAL AID
MOMENTUM
FEDHEALTH MEDICAL AID
GEMS MEDICAL AID
MEDSHIELD MEDICAL AID
BANKMED MEDICAL AID
BONITAS MEDICAL AID BON0979511
ENGEN MEDICAL AID
5
Membership Status
Main Member
Dependant
6
Medical Aid Number
7
Patient Name* This field is required.
Mr.
Mr.
Mrs.
Miss
Dr.
Prof.
Tittle
First Name
Last Name
8
Patient Phone Number* This field is required.
Area Code
Phone Number
9
Patient Identity Number
10
Patient Email* This field is required.
example@example.com
11
Consulting Doctor
Please Select
Please Select
Dr. M.B Lelimo
Dr. M. Kolobe
Dr. L. Letlala
12
Doctor Email* This field is required.
example@example.com
13
Types of Consultation* This field is required.
Diagnostic consultation
Remote consultation
Primary care consultation
Mental health support
Psychoanalytic or Psychodynamic Therapy
14
Medical History* This field is required.
15
Resp Patten blanks
Spo2 blank %.
Temp Celcious
16
Blood Pressure blanks mmHg
Pulse Rate blank bpm
RBS %
17
Additional Medical Notes
18
Phone Number* This field is required.
Area Code
Phone Number
19
Appointment Date & Time
Please Select
Please Select
Consult Doctor Now.
Book Appointment With a Doctor
20
Consulting Doctor* This field is required.
First Name
Last Name
21
Please Select an Appointment Date* This field is required.
22
Attach Patient Documents
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
Pharmacist Signature* This field is required.
Clear
24
Client Signature* This field is required.
Clear
Should be Empty: