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TELE-MED Registration & SAHPRA Sec21 Application details

To register, please take the time to fill out the information below.

Submission Time
First Name
Last Name
Email
Cell Phone Number
Birthday
Physical / Business Address:
First time registering?
Relevant sessions
Do you have any Known allergies? If Yes Please List
Next of Kin Name & Contact Number
Please list your known medical conditions & Treatment
Please list your current symptoms
Medical Aid & Plan
Email 2
I agree to the terms & conditions of the Practice
Enter medical aid number
Photo for your Personal Medical File
Dependant code E.g (00) (01)
Covid-19 Rapid Test Result
Temprature, Pulse, Blood Presssure
Title
Weight
Height
Gender
New Field-1
No
No
No
No
No
No
No
No
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