Please complete this form and submit it to Dr Haffejie

* Name & Surname

Phone

* Mobile

* Email Address

Address Enter your physical or postal address here.

* Preferred Date

* Preferred Times

Nature of your problem / reason for requesting appointment

* Message Enter description of problem here here.

Contact Dr Haffejie at +27-11-315-4028 or +27-11-805-3731

Email : haffejie@gmail.com

* Verify