Patient Portal

New Patient Registration

Complete your registration to become a patient at Swartland Medical Centre. All information is kept strictly confidential in accordance with POPIA.

Note: This form is for new patient registration only. Existing patients with urgent medical concerns should call 022 482 2552 directly.

Personal Information

Title

Preferred Language

First Name *

Last Name *

Preferred Name

SA ID Number *

Date of Birth *

Gender *

Contact Information

Mobile Phone *

Alternative Phone

Email Address *

Residential Address *

City / Town *

Postal Code

Medical Aid

I have medical aidPrivate / Cash patient

Medical History

Known Allergies (medications, food, latex, etc.)

Current Chronic Medications

Known Chronic Conditions

Previous Surgeries / Hospitalisations

Emergency Contact

Contact Name *

Relationship *

Contact Phone *

Additional Information

How did you hear about us?

Preferred Doctor

I consent to Swartland Medical Centre collecting and processing my personal and medical information for the purposes of patient registration, appointment management, and healthcare delivery. I understand that my information is protected under POPIA and will not be shared with third parties without my consent, except as required by law or for my clinical care. I confirm that the information provided is accurate to the best of my knowledge. I have read and agree to the Terms & Conditions and Privacy Policy.