Joining Us > Application Form

Customer Application

Complete your details below and we will contact you.

Principle Member Information
Initials: 1st Name: *
Surname: * ID No.: *
Medical Aid: Medical Aid No.:
Option: Pensioner:
Tel Work: Home:
Cell: E-mail: *
   
Patient 1 Information
Patient 2 Information
Initials: Initials:
1st Name: 1st Name:
Surname: Surname:
Tel Work: Tel Work:
Cell: Cell:
ID: ID:
Gender: Gender:
Doctor: Doctor:
 
Address Detail
   
Home/ Physical Address
Postal Address (If different to home)
Building: Line 1:
Street & No.: Line 2:
Suburb: Suburb:
Town/ City: Town/ City:
Postal Code: Postal Code:
 
Work Address
Building: Street & No.:
Suburb: Town/ City:
Postal Code: Please Deliver to my:
 
Service Required
Please deliver my medication to the indicated address - By Request Automatically every 28 days
Do you agree to generic substitution? Yes No
Do you agree to therapeutic substitution? Yes No
I need my first medication on - (Subject to Medical Aid approval)
 
Type the exact characters in the exact order in the space provided and submit. This is a captcha-picture. It is used to prevent mass-access by robots. (see: www.captcha.net)
 
 

The applicant acknowledges that he/she is responsible for payment of any levies, co-payments or rejections that the medical scheme may impose, and to inform Pharmacy Direct of any changes to his/her medical aid detail. Only written cancellations of this application will be accepted.

* - required field