Schedule an ENT Specialist Consultation

Dr Glen Monama • MBChB (Medunsa), MMed (UL) • Specialist Otorhinolaryngologist & Surgeon

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Patient Demographic Details

Patient First Name

Patient Last Name

SA ID or Passport Number

Date of Birth

Age

Gender

Population Group / Race (HPCSA Record)

Patient Phone

Patient Email Address

Residential Address

Medical Aid Details (leave blank if paying privately)

Medical Aid Scheme

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Plan / Option

Dependency Code

Clinical Context & Reason for Consultation

Describe the ENT Problem or Symptoms You Are Facing

Have you previously seen a doctor / GP regarding this specific issue?

Preferred Appointment Date

POPIA Compliance & Confidentiality Undertaking

In accordance with the Protection of Personal Information Act (POPIA Act 4 of 2013) and HPCSA ethical rules, your special personal information and health records are processed with strong encryption strictly for diagnosis, appointment administration, and surgical scheduling. Your information is never sold or shared with third parties for marketing purposes.

I hereby consent to the processing of my medical and personal details by Dr GM Monama.

Financial Responsibility Agreement

The consultation fee is R1,200 (cash-paying patients) or R600 (medical aid patients). No-shows are charged the full consultation fee. Cancellations must be made at least 24 hours before the appointment to avoid being charged. Read the full Financial Responsibility Agreement.

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