Medical Aid Plan costs how much?

YES or NO

Do you want ONLY hospital cover?

YES or NO I want doctor, chemist, dentist and glasses.

Your Name

Your Email

Your Telephone

Your City

How many adults?

Your age

Total number of years (from age 35) you have been a medical aid member

Your Partner's age

Total number of years (from age 35) your partner has been a medical aid member

How many children?

Your current medical aid and plan

How much can you spend a month?

Any chronic conditions?

What do you want from a medical scheme?

I confirm that I have read and understood the notes below and agree to further communications sent to me. Yes