Counseling and Health screening
Book your Health and Counseling - Hester de Lange 0828437247 for any further queries.
Personal info
Name & Surname *
Your answer
Email address *
Your answer
Contact number
Your answer
Describe the problem
Summary *
Your answer
Type *
Priority *
Very high
Very low
Booking Date *
More details:
Your answer
I understand this is a registration booking form. Payments are made before each session via eft as we do not accept cash payments. Booking confirmation will be sent upon receipt thereof. We charge within medical aid rates that you could claim back if your medical aid cover Counseling and Health screening.
Banking details:
Veritas Educare
Capitek bank Greenstone
Reference is your initial and surname
Account number: 1477529312
​send POP to:
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy