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Please note that this is not an application form for membership, it is only an enquiry form about membership.

Once we receive your enquiry, one of our consultants will contact you to discuss the plans we offer and to highlight any important information.

New Membership enquiry

Principal Member contact details

Fields marked with * is compulsory

Name and Surname*
Landline number
Cellphone number*
Email address*

Principal Member current medical scheme

If you currently belong to a medical scheme, please provide the name

Referral details

Where did you hear about Cape Medical Plan?*
If you would like to add anything to the above information, please type your message here.
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