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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
(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


E-2. Previous Surgery - Orthopaedic/Musculoskeletal


F. Current Knee problem

G. Imaging

Click or drag a file to this area to upload.

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.


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