MEMBER/PROVIDER LOGIN
USERNAME
PASSWORD
REGISTER

PASSWORD REMINDER



Are you enquiring on behalf of your company?

Private Membership Questionnaire
First Name:
Surname:
Age:
Do you have any dependants?

Have you or any of the family members been hospitalised in the last 12 months? Please indicate conditions.
Main Member:

Have your or any of the family members got chronic conditions? Please indicate conditions.
Main Member:
Do you currently belong to a medical aid? Please supply name:
Why have you considered leaving?
Other Reasons
Telephone Number:
Cell Number:
Email Address:
Address:
Town:
Province:
Does your company subsidise meical aid subscriptions?
For reference purposes, please supply the name and telephone number of your company. Company Name

Telephone Number
Can we contact your employer regarding other people within the company that may be interested in Cape Medical Plan?
Who can we speak to?
Where did you hear about Cape Medical Plan?