Sign Up – Doctor Sandra Hamilton

Surname *

Christian Name *

Address *

Phone Number-Home

Cell Phone *

Date of Birth *

Age *

Height *

You may type your height like this "5ft. 11 inches " or 1.8m

Weight *

Enter your weight in lbs, kg or st

Relationship status *

SINGLE MARRIED

Number of children

Employer *

Occupation *

Favourite colour: *

Hobbies *

HEALTH

Doctor’s name and address

Date of last check up

Check the boxes for your areas of concern:

You may select multiple boxes by holding down the CTRL key on your keyboard while clicking each item.

Method of payment: cash, PayPal, bank lodgement 

I accept that all appointments not canceled with 48 hours notice will be charged in full.