Membership Application

Fill in the Form below, or download it as a PDF – 

Application For Membership
  • Personal Details
    0
  • Salutation*select your country
    1
  • Surname*
    2
  • First Name*
    3
  • Initials*
    4
  • Identification Number*full name
    5
  • Date of Birth*
    6
  • Country of Origin*select your country
    7
  • Residential Adress*full name
    8
  • Email*a valid email address
    9
  • Phone Number*full name
    10
  • Other Number*full name
    11
  • Packages
    12
  • Which Package Would you Like to Join*you like
    Opal International Plan
    Sapphire Plus Plan
    Sapphire Plan
    Ruby Plan
    Amber Plan
    Coral Plan
    Topaz Plan
    13
  • If other please state which*full name
    14
  • Dependants
    15
  • Name*full name
    16
  • Relation*full name
    17
  • Sex*select your country
    18
  • Name of Doctor*full name
    19
  • Name*full name
    20
  • Relation*full name
    21
  • Sex*select your country
    22
  • Name of Doctor*full name
    23
  • Name*full name
    24
  • Relation*full name
    25
  • Sex*select your country
    26
  • Name of Doctor*full name
    27
  • Previous Medical Aid
    28
  • Medical Aid*full name
    29
  • Scheme/Plan*full name
    30
  • From*make a booking
    31
  • Expiry*make a booking
    32
  • Health History
    33
  • Do You or Have You Ever Suffered From The Following?*you like
    Cancer
    Push Conditions
    Hypertension
    Diabetes
    Leprosy
    Renal Disease
    Cardiovascular Problems
    Epilepsy
    Asthma
    Other
    34
  • Please Specify Other*full name
    35
  • Agree and Send
    36
  • 37