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CANSA Employee Wellness Booking

Contact Person*
First Last
Name of Company / Organisation*
VAT Number
Email*
Phone Number*
Mobile Number*
Address for Invoice*
Street Address Address Line 2 City/Town Province Postal Code
Address where services are to be rendered*
Street Address Address Line 2 City/Town Province Postal Address
Requested date of services*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Please select your topic(s)
Please enter the number of people to be screened

ADULTS:
Blood pressure test*
Blood glucose test*
MEN'S HEALTH TALK & SCREENING:
Prostate cancer talk*
Testicular cancer talk*
Prostate Specific Antigen (PSA) blood test (max 30 per nurse)*
WOMEN'S HEALTH TALK & SCREENING:
Cervical screening (Pap smear) & Clinical Breast examination (max 20 per nurse)*
Clinical breast examination (max 30 per nurse)*
Breast Examination with Breastlight*
Breast Self Examination demonstration*
Breast Cancer talk*
Cervical Cancer talk*
LIFESTYLE & OTHER CANCER TALK & SCREENING:
Adult healthy lifestyle talk*
Tobacco awareness talk*
SunSmart awareness talk*
Environmental risks talk*
Mole analysis (FotoFinder)*
Clinical Mole analysis*
Faecal Occult Blood Home Test*
Lifestyle risk assessment*
Audience Demographic

Please enter the number of people
Male*
Female*
Youth*
Middle Aged*
Elderly*
Select a CANSA Community Service*
- Exhibition half day (4 hours)
- Exhibition full day (8 hours | includes 1 hour CANSA educational talk)
- CANSA educational talk (Max. 1 hour | Any cancer related topic)
- CANSA Mobile Clinic
Consent*
The quote will need to be approved by the company and the deposit paid 2 weeks prior to the wellness day. Once this has been received, CANSA services will be booked. The approved wellness quote will serve as the minimum payment for the specified services. Should more screenings be conducted or the nurses time be extended, the final invoice will be amended with these additions. Please note, if less than 10 screenings are conducted on the day, for whatever reason, CANSA has the right to amend the prices for the screenings. it will be (price per screening x 10) + VAT = total for screenings. Please note, an additional fee of R200 (incl VAT) per hour may be charged as an additional service delivery/professional nurse fee. If a client wishes to reduce, cancel or amend services booked through CANSA, at least 24 hours notice must be given. Failure to do so will result in a cancellation fee being charged equal to four hours nursing fees.
I agree that i have read and understood the booking form and that the information provided is correct.*
By submitting your details, you agree to receive communication from The Cancer Association of South Africa (CANSA).

We undertake to treat your information confidentially and will not pass them on to third parties.
Consent*
I herewith give permission that personal information which is required may be stored on paper-based and/or digital systems of CANSA and may be used for the purpose of the project / service required. I consent to CANSA using my data for statistical purposes (no personal information will be used). Statistics will be used for internal research and for external stakeholders’ information only.
Yes*

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CANSA Employee Wellness Booking

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CANSA Employee Wellness Booking

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