Anaesthetic Cost Estimation

To give you the most accurate anaesthetic cost estimation possible, we will need some of your details.

Should you want to request a formal cost estimate for the anaesthetic during an upcoming procedure, you can do so by completing and submitting our Anaesthetic Cost Estimation Request Form.

Please complete the aforementioned form in full and we will get back to you once our doctors have evaluated your information.

In order for us to respond via email, fax or telephone, it is important to note that all the fields on the form are mandatory and needs to be completed in full.

PLEASE NOTE

All fields are mandatory in order to generate the request
You will receive purely an anaesthetic cost estimate – a quotation
The Anaesthetic Cost Estimation Form/Quotation must accompany you on the day of your surgery for reference to the attending anaesthesiologist

    Patient Information

    Title

    Initials

    Name

    Surname

    Birth Date

    ID number

    E-mail

    Telephone number

    Physical Address

    Weight of Patient (kg)

    Height of Patient (cm)

    Medical Aid Information

    Medical Aid

    Medical Plan/Option

    Medical Aid Number

    Do you have GAP cover?

    Surgery Information

    Planned Surgery

    Surgeon

    Date of planned surgery

    Hospital

     

    Drs. Nell, Scheepers and Van der Nest

    Specialist Anaesthesiologists

    An Association of Specialist Anaesthesiologists in Witbank and Middelburg and the surrounding area, covering all aspects of anaesthesia, including elective and emergency procedures.