Providing medical aid advice for South Africa

Online Enquiries

Whether you are looking for a simple hospital plan or more comprehensive medical aid cover, Selfmed has the right option for your needs.
We know the form below might seem long, but the more information our consultants have at their fingertips, the better advice we can offer you and your family!
Go on... take 5 minutes to complete the form... and help us help you!

NB: We would not recommend that you join an option of which the contribution amounts to more than 10% of your household monthly income. Should the Selfmed option contribution that you are considering fall within a range that would exceed 10% of your monthly income and you are still interested and wish to find out more, please continue:

Do you want to see a consultant?	Yes No
Title
First name	*
Surname	*
Applicant's Age
ID Number
Applicant's Job Description
Monthly Household Income	*
Telephone no.	*
Facsimile no.
Cellphone no.
E-mail address	*
Postal Address
Postal Code
Province	*
Employer
Employment Sector	Private State
Subsidy	Yes No If Yes Percent
Details of Current Medical Aid Scheme
Name of Medical Scheme
Which Option?
Monthly Contribution
Are you interested in a specific Selfmed option?
How Many People in your Family?
Member
Spouse
Dependants over 21
No. of children under 21
Chronic Medicine Users
Number of chronic users in family
Cost of chronic medicine per month
Chronic conditions / specify
Day-to-Day Benefits (e.g. doctors and acute medicine)
Required	Yes No
Monthly Amount
If you and/or you spouse or partner are over 34 years of age, please complete the following.
On a medical scheme before 1/4/2001 to date?	Yes No
Have you previously belonged to a medical scheme as an adult?	Yes No
If YES, years in total
Name of scheme(s)
Any further requests or comments
Where did you hear about Selfmed?
Please input the text on the left.