Home»Contact Us Call Us 012 440 1305 Email Us consultation@dr.ojajewole.com Address 296 Justice Mahomed St, Sunnyside, Pretoria, 0002 Fill In The Form To Book Your Appointment Patient Intake Form (#4)First NameLast NamePatient AgePrefered Name / NicknamePatient Gender- Select -MaleFemaleOthersPhone no.Spouce NameWith whome do you live?Marital status(other)OccupationRetired? Yes NoDate of retirementDisability ? Yes NoDate of disabilityWho is your primary care doctor: Where is your primary care doctor located ? Phone Number of primary care doctor:allergic to any medications Yes Noallergic to any medicationsDo you smoke? Yes NoHow many years did you smoke?If you quit, when did you stop?Do you drink alcohol? Personal opinionSubmit