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Our Team Book Here Reviews

Our Team Book Here Reviews

New Patients

Patient intake form.

If this is your first visit, please complete this form before your appointment. It takes about five minutes.

Company

Patient details

First names *

Last name *

Patient ID number *

Relevant medical information

Tick anything that applies. This helps your physiotherapist treat you safely.

Smoker Diabetes Allergies Asthma Arthritis High cholesterol Epilepsy Cancer Deep vein thrombosis (DVT) High or low blood pressure Other

If other, please give details

Person responsible for the account The person responsible for the account is the same as the patient

Untick the box above if someone else is responsible, for example a parent or spouse. The contact details below are always required.

First names

Last name

ID number

Email *

Phone *

Alternate phone

Address

Street address *

Address line 2

City *

Province *

Postal code *

Country *

Medical aid details

Tell us how you are paying. If you are on a medical aid, choose it below and the details will appear.

How are you paying?

Medical aid Private (cash)

Medical aid

Plan / option

Medical aid number

Dependent code

Consent I have read and accept the Terms of Use and Privacy Policy. I consent to physiotherapy assessment and treatment, and I understand that fees are charged per treatment code and that I am responsible for payment, including any amount my medical aid does not cover. I consent to Menlo Physio collecting and processing my personal information, including health information and medical aid details, for my physiotherapy treatment and for managing my account and billing. I understand my information is submitted to the practice electronically and handled in line with the Privacy Policy. I may access, correct, or delete it, or withdraw this consent, by contacting the practice. Giving this information is voluntary, but the practice may be unable to treat me without it.

Sign and date

Date *

Thank you. Your details have been sent to the practice. We will be in touch to confirm your appointment.

Something went wrong sending your form. Please try again, or contact the practice on WhatsApp.

Sports and performance physiotherapy in Menlo Park, Pretoria.

Hoërskool Menlo Park
Menlo Park, Pretoria
Monday to Friday, by arrangement

© 2026 Menlo Physio. All rights reserved.

Privacy Terms HPCSA compliance

The information on this website is general and does not replace a professional consultation, diagnosis or treatment. In a medical emergency, contact emergency services immediately.

Menlo Physio is the shared name of two independent physiotherapy practices. Both practitioners are registered with the Health Professions Council of South Africa (HPCSA).

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