Medical Aid Information

You can download the Medical Aid Information form or fill in the online form below.

Main Member Information

Gender MaleFemale

Email Statement YesNo

GAP Cover YesNo


Patient Information

Use this number for appointments/test results YesNo
Main member's cellphone number will be used if the above is "No".

Gender MaleFemale


Next of Kin (Not from same physical address)


Hereby I confirm that the information supplied is true and I am responsible for any false information provided.

I Agree

Allow mass communication or notices from practice