Profmed Input Form

Personal Details

Title

Surname

Name

Please note: at least one contact number is required!
Use this number in all three fields if no other contact numbers

Mobile number

Telephone No: Home
(include area code)

Telephone No: Work
(include area code)

Fax No:
(include area code)

Email Address

Identity Number:

University Degree
eg. BSc(QS), MBChB, BIng, MBA
Please Note- Profmed Membership: You must be an existing PPS member or qualify for PPS Membership.
If Not, click here for a free online comparative quote on SA's top medical aid funds.

Occupation

Income per month (R)

Employment Sector

Subsidy
Yes
No, If "Yes" %

Province

Specific Information

Current Medical Scheme (type "None" if no current scheme)

Which option ?

Premium per month (R)

People in family
Principal Member
Spouse partner

Adult dependants over the age of 21

Children under the age of 21

Number of chronic users

Cost per month (R)

Specify chronic conditions(s)

If you and/or your spouse are older than 34 years of age please complete the following:
Have you belonged to a Medical Scheme/s before 1 April 2001 to date?
Yes
No, If "No" please complete the following:

Have you previously belonged to a Medical Aid as an adult?
Yes
No, If "Yes" indicate how many years

Name of previous scheme

Would you like cover for:
day-to-day expenses
hospital plan only

Comments

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