MEDICAL AID QUOTE Please enable JavaScript in your browser to complete this form.Name *FirstLastNumber *Email *Age (Main Member) *Monthly Income (Main Member) *Current Medical Aid Status *Current Medical Aid StatusI am currently on a Medical Aid and have been for longer than 2 yearsI am currently on a Medical Aid and have been for less than 2 yearsI have not been on a Medical Aid for the last 3 monthsCurrent Medical Scheme *Beneficiary (spouse/partner) *Beneficiary (spouse/partner)Yes, I want to add a spouse or partnerNoAdd Adult dependents *Add Adult dependentsNo, that is it!Yes, 1 more2 more3 moreMore than 3 AdultsAdd Child dependents *Add Child dependentsNo, that is it!Yes, 1 more2 more3 moreMore than 3 ChildrenChronic conditions *Chronic conditionsYesNoDay to day benefits *Day to day benefitsI am not really concerned about these benefitsI would like to have it covered if I can afford itIt is very important to meHospital provider preference *Hospital provider preference I want to be able to go to any hospital I chooseI am happy to use the schemes private network hospitalsI will go to a state hospital if needed to get the cheapest medical aidCity of Town you live in? *Your can give more info on any chronic conditions if you want to.Is there anything else you think we should know?Privacy Policy *I agree to the Privacy PolicyBy submitting this form you agree to the terms of the Privacy Policy, which means we undertake to protect your personal data in compliance with the Protection of Personal Information Act.SUBMIT
