This is a remote consultation allowing us to compose a pre-clinical diagnosis and suggested treatment. A final diagnosis and specific treatment can only be done once a formal clinical examination has been conducted.

The bill for this pre-clinical consultation is R500, payable upon completion of this form.

Should you come for a final clinical evaluation, diagnosis and treatment plan; that consultation will only be R400 (our standard consultation fee is R950).
Due to patient confidentiality, family members cannot contact the doctor on behalf of another family member.

By completing this online form, you freely and voluntarily consent to this service, and understand the implications thereof, including the costs related to it.

Banking details:

The Knee Clinic
ABSA Private
Branch 630710 (Stellenbosch)
Savings Account: 9061236102

The pre-clinical consultation is R500.

We will only respond once we have received proof of payment which can be send to account@kneeclinic.co.za.
(Please use your Initials and Surname as reference).

A. Patient Details



B. General Health





C. Current Medication (if applicable)



D. Particulars of other Treating Physicians



E-1. Previous Surgery - General

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E-2. Previous Surgery - Orthopaedic/Musculoskeletal

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F. Current Knee problem



G. Imaging


Click or drag a file to this area to upload.
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H. Leg Alignment

H-1 Photo Upload:


Please refer to THIS PDF DOCUMENT* and upload 3 images as per the instructions on the PDF document.

Click or drag a file to this area to upload.

H-2 Leg Alignment:


Please refer to THIS PDF DOCUMENT* and looking from the front, what is the alignment of your leg – the two sides might differ.



I. Range of Motion

Range of Motion:


Please refer to THIS PDF DOCUMENT* Looking at the sketch, how far can you extend (straighten) and how far flex (bend) the knee.




* DISCLAIMER AND CONFIDENTIALITY NOTICE: KNEECLINIC

The information contained in this e-mail communication is confidential. This information is intended solely for the use of the intended recipient named above. If you have received this e-mail communication in error, please notify the sender immediately, and forward it to the intended recipient, if you are aware of who the intended recipient is and delete this e-mail from your e-mail system immediately. In the event that you are not the intended recipient, you are hereby notified that any disclosure, distribution, use of, printing, copying or other action on the contents of this e-mail communication is strictly prohibited. This e-mail communication and its contents are not intended to be legally binding on KNEECLINIC or the sender hereof nor should the contents hereof be construed to amend any contractual arrangement in place, unless explicitly stated herein. KNEECLINIC accepts no liability for any loss or damage, whether direct, indirect, consequential or economic, however caused, which may result directly or indirectly from this e-mail communication or from any files attached hereto. Save for bona fide company matters, KNEECLINIC does not accept any responsibility for any material, views or opinions contained in this email. This email is further subject to the provisions of the Protection of Personal Information Act 4 of 2013.