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Please complete the form below, it will take less than 2 minutes, for an
INSTANT, ONLINE - NO OBLIGATION
medical aid quotation.
Tell us about yourself
First Name
Last Name
Cell phone / Mobile No.
Additional Contact No.
Email address
Personal Information
No. of Adults
Choose...
1
2
3
4
5
6
No. of Children
Choose...
0
1
2
3
4
5
6
7
8
9
10
Monthly Income
Over R12000
Below R12000
Specify Income
Currently on a Medical Aid?
Choose...
Currently not on a Medical Scheme
Anglo Medical Scheme
Anglovaal
Bankmed
Barloworld
Bcima
Bestmed
Bonitas
Camaf
Cape Medical Plan
Compcare
Discovery
Fedhealth
Gems
Genesis
Imperial Motus Med
Keyhealth
La Health
Libcare
Makoti
Massmart
Medihelp
Medimed
Medshield
Momentum Health
Motohealth
Omsmaf
Platinum Health
Polmed
Profmed
Remedi
Sabmas
Samwumed
Sisonke
Sizwe Hosmed
Suremed
Thebemed
Transmed
Umvuzo
My Medical Scheme is not in the list
Medical Scheme Name
Medical Scheme Option
Choose...
Health Questions
Hospital Provider
i
Scheme Appointed
Own Choice
Day-2-Day cover
i
Scheme Appointed
Own Choice
None
Level of Cover
i
Limited
Medium
High
Interested in Gap Cover?
i
Yes
No
Require Chronic Medication?
Yes
No
Interested in a loyalty program?
Yes
No
Protection of Personal Information Act (POPIA) Declaration
By providing the information in this form you agree that our fulfillment partner may contact you to provide you with the necessary advice. Your personal information will be stored in a secure encrypted manner and will not be sold or disseminated to any third party without your explicit consent.
I Accept