Complete the form below or telelphone 0860-SELFMED, email: marketing@selfmed.co.za
We would not recommend that you join an option of which the contribution amounts to more than 10% of your household monthly income. Should the Selfmed option contribution that you are considering fall within a range that would exceed 10% of your monthly income and you are still interested and you wish to find out more, please continue
Do you want to see a consultant?
Yes No
Title
First name
Surname
Applicants Age
ID Number
Aplicants Job Description
Monthly Houshold Income
Telephone no.
Facsimile no.
Cellphone no.
E-mail address
Postal Address
Postal Code
Province
Employer
Employment Sector
Private State
Subsidy
Yes No If Yes Percent
Details of Current Medical Aid Scheme
Name of Medical Scheme
Which Option?
Monthly Contribution
Are you interested in a specific Selmed option?
How Many People in your Family?
Member
Spouse
Dependants over 21
No. of children under 21
Chronic Medicine Users
Number of chronic users in family
Cost of chronic medicine per month
Chronic conditions / specify
Day-to-Day Benefits (e.g. doctors and acute medicine)
Required
Monthly Amount
If you and/or you spouse or partner are over 34 years of age, please complete the following.
On a medical scheme before 1/4/2001 to date?
Have you previously belonged to a medical scheme as an adult?
If YES, years in total
Name of scheme(s)
Any further requests or comments
