Register

Please complete the form below to register. You will be redirected to the login page in order to login and make an appointment.

Username*

First Name

Last Name

E-mail Address

Password*

ID Number

Phone Number

Mobile Number

WhatsApp number

Gender

MaleFemale

Other

Do you have any chronic medical conditions?

Please list any medical family history

Do you take any chronic medications?

YesNo

If yes, please list chronic medications used and quantities

Image of medications (.jpg)

Medical Aid

Medical Aid plan

Medical Aid number

Dependent code

Copy of card (,jpg)

I hereby consent to the personal information provided by me to be used for delivery of services offered by Dr Hart Incorporated.
It is my legal obligation to provide correct information in the contracting with Dr Hart Incorporated and where such information has been changed, I am obliged to inform Dr Hart Incorporated accordingly.
I am aware that I can unsubscribe to any newsletters, campaigns, communications from Dr Hart Incorporated by notifying them accordingly.
It is my right to request Dr Hart Incorporated to delete and cease to use any of my personal information subject to any legal obligation on Dr Hart Incorporated’s side to keep same.
There is a legal obligation for Dr Hart Incorporated to retain your information for 5-years from date of contracting, whereafter it will be destroyed in a POPIA compliant manner.
Should I believe that there has been a misuse of my personal information, I am aware that I can lodge a complaint with Dr Hart Incorporated and / or the Information Regulator at inforeg@justice.gov.za

I hereby acknowledge that I understand and agree to the above mentioned statements.

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