Request an Appointment with one of our Specialists

Complete this form to request an appointment at our medical centre. Our Patient Care Coordinator will contact you via phone or email to confirm the appointment.

Name

E-mail

Phone Number

Which of our services would you like to use?*

Which specialist would you like to see? (Optional)

Your Preferred Date (Optional)

Your Preferred Time (Optional)

By submitting this form I understand that Qualitas Health will protect my information in accordance to the Personal Data Protection Act 2010.