Title Dr Prof Mr Ms Mrs Miss

South African ID Number

Email Address

Phone Number

GP Type Non Procedural Non Procedural Ante Natal - no sonars Non Procedural -Ante Natal - foetal scans up to 12 weeks Procedural including Aethestics Treatments Procedural Aesthetics including Botox, Fillers, Threads (Aesthetics less than 50%) Procedural Aesthetics including Botox, Fillers, Threads (Aesthetics more than 50%) Accident and Emergency

Do you work in the public or private sector? Public Private Both

Medical Council Registration Number

Please list all your registered qualifications including any post–graduate qualifications, where and when this was obtained

Have any claims / incidents / circumstances for malpractice been made against you / practice during the past five years? Yes No

Please provide details:

Cover Limit R 2.5M R 5M R 10M R 20M R 30M

Estimated Premium per Month:

Would you like more information on this quote? Yes No

Reason