Botshilu Bambinos

Taking baby steps with you.

Unique ID
About Mommy
Name*
First Last
ID Number*
Date of birth*
DD slash MM slash YYYY
Phone*
Email
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
About your Baby:
Estimated Delivery Date (EDD)*
MM slash DD slash YYYY
Boy or Girl?*
- Boy
- Girl
- Don't know
Twins ?*
- Yes
- No
Who is your Doctor? e.g. GP Dr (insert surname) or Obs & Gynae Dr (insert surname)
About your Medical Aid
Are you on Medical Aid?*
- Yes
- No
If yes, what is your Medical Aid Scheme, e.g. Discovery
Medical Aid Option
Were you planning to give birth in Botshilu Private Hospital?
- Yes
- No
If no, which hospital?
Where did you learn about our Botshilu Bambinos Programme?
- Reception
- My Doctor's room
- Maternity Unit
- Website
- Facebook
- Twitter
- Word of mouth
- Pregnancy Education Event
Do you give us permission to use your contact details to send you other information about the hospital?*
- Yes
- No
Consent
I agree to the privacy policy.
What is your preferred method of communication?*
- Email
- Cell number
Please ensure that you captured your correct contact details in the above section.
Email
This field is for validation purposes and should be left unchanged.

Emergency Room	012 798 7076
Nationwide Emergency Response	10111
Nationwide Ambulance Response	10177
Botshilu Emergency Room & Casualty	Read More

For assistance

	012 798 7000
	ERF 212, Block IA, Buitenkant Street, Soshanguve, 0152

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