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[[[["field2","equal_to","General Practice"]],[["show_fields","field10"]],"and"],[[["field11","equal_to","Yes"]],[["show_fields","field21,field12"]],"and"],[[["field12","equal_to","Yes"]],[["show_fields","field13,field14,field15,field17,field18,field19,field22,field16"]],"and"],[[["field8","equal_to","yes"]],[["redirect_to",null,"https:\/\/www.mediwell.co.za\/thank-you-contact\/"]],"and"]]
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Surnameyour full name
Phone Numberyour full name
Appointment Dateof appointment
Timeof appointment
Physical Addressyour full name
Provider
Medical Aid Number
Plan TypeMember Plan

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