urogynaecology — Appointments

Your Journey Starts Here

When you choose us, you’re not just a patient but part of our community.
Let’s work together to enhance your pelvic health and empower you to live life fully.
Book your appointment today and take the first step toward a healthier, happier you. We’re here for you every step of the way.

New Patients
Welcome to Our Clinic (ULC)

As a new patient, please make sure to complete the following documents before your first consultation:

New Patient Info
Patient Questionnaire
Patient Co-payment

Kindly ensure the completion of the forms provided. You may download, print, and fill them out. Upon completion, please proceed to scan and email the forms to our office or bring them along during your visit. We appreciate your cooperation.

For those unable to fulfil this requirement beforehand, please plan to arrive 15 minutes before your appointment. Thank you!

Click on the preferred button below to complete online forms

New Patient Info

PATIENT INFORMATION

Title

Full Name

First Name

Last Name

ID Number/ Passport Number

Gender

Date of Birth

Age

Cell Number

(###)

###

####

Cell Confirmation

Use this number for appointments/Test Results?

Yes

No

Work/Alternative Number

(###)

###

####

E-mail

Home Language

Occupation

Marital Status

Relationship to main member

Height

Weight

Referring Doctor

Ref. Dr. Telephone

(###)

###

####

MAIN MEMBER INFORMATION

ID Number/ Passport Number

Title

Full Name

First Name

Last Name

Date of Birth

Gender

Cell Number

(###)

###

####

E-mail

E-mail Statement?

Yes

No

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Language

Medical Aid/Insurance Information

Medical Scheme

Plan/Option

GAP cover

YES

No

Member Number

NEXT OF KIN

Should not reside at the same address

Full Name

First Name

Last Name

Title

Cell Number

Relationship to patient

Digital Confirmation

You will be required to sign in person

Full Name

First Name

Last Name

Today's Date

MM

DD

YYYY

Digital Signage

I the above named confirm that the information I supplied is true and I am responsible for any false information provided

Make A Booking

Name & Surname

First Name

Last Name

Email

Subject

How can we help?

Patient Questionnaire

Pelvic Floor Distress Inventory Short Form (PFDI-20)

Instructions: Please answer all of the questions in the following survey. These questions will ask you if you have certain bowl, bladder, or pelvic symptoms and, if you do, how much they bother you. Answer these by selecting the appropriate number. While answering these questions, please consider your symptoms over the last 3 months. The PFDI-20 has 20 items and 3 scales of your symptoms.

Full Name

First Name

Last Name

ID/Passport Number

Date of Birth

Date

MM

DD

YYYY

Timeline

Pre

3 Month

6 Month

12 Month

24 Month

36 Month

60 Month

Do you usually experience pressure in the lower abdomen?

If yes, how much does this bother you

Do you usually experience heaviness or dullness in the pelvic area?

If yes, how much does this bother you

Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?

If yes, how much does this bother you

Do you have to push on the vagina or around the rectum to have or complete a bowel movement?

If yes, how much does this bother you

Do you usually experience a feeling of incomplete bladder emptying?

If yes, how much does this bother you

Do you usually have pain when you pass your stool?

If yes, how much does this bother you

Do you ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination?

If yes, how much does this bother you

Do you feel need to strain too hard to have a bowel movement?

If yes, how much does this bother you

Do you feel you have not completely emptied your bowels at the end of a bowel movement?

If yes, how much does this bother you

Do you usually lose stool beyond your control if your stool is well formed?

If yes, how much does this bother you

Do you usually lose stool beyond your control if your stool is loose?

If yes, how much does this bother you

Do you usually lose gas from the rectum beyond your control?

If yes, how much does this bother you

Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement?

If yes, how much does this bother you

Does part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement?

If yes, how much does this bother you

Do you usually experience frequent urination?

If yes, how much does this bother you

Do you usually experience urine leakage associated with a feeling of urgency, that is? A strong sensation of needing to go to the bathroom?

If yes, how much does this bother you

Do you usually experience urine leakage related to coughing, sneezing or laughing?

If yes, how much does this bother you

Do you usually experience small amounts of urine leakage (that is, drops)?

If yes, how much does this bother you

Do you usually experience difficulty emptying your bladder?

If yes, how much does this bother you

Do you usually experience pain or discomfort in the lower abdomen or genital region?

If yes, how much does this bother you

Co-Payment Forms

What to bring to your Appointment

To ensure a smooth and efficient visit, please bring the following items to your appointment:

Medical Aid Card

Bring the most recent card issued by your medical aid to confirm your eligibility.

Referral Letter and Relevant Tests/Investigations

Please bring any referral letters and relevant tests or investigations that were previously conducted.

Payment for Your Visit

The first consultation includes an ultrasound and costs R2350, excluding other tests such as lab costs for pap smears and urine culture, and Urodynamic studies. A statement with a receipt will be provided, which you can submit to your medical aid for partial reimbursement.

Out-of-Town Patients
Welcome to Our Out-of-Town Patients

Prof. Jeffery has extensive experience in providing medical care to female patients from various regions of South Africa and overseas. Patients frequently travel from Namibia, Zimbabwe, Zambia, Botswana, Dubai, Tanzania, and even the UK and USA to seek treatment.

Prof. Jeffery provides free Skype, Facetime, or phone consultations for women who are thinking about surgery, making the admission process as smooth as possible. For more details, please get in touch with our office.