Join MediCoop

If you are a healthcare professional, healthcare worker or medical industry stakeholder and comply with the minimum requirements, you can either complete our Member Application Form below (online application process) or you can follow our manual application process by downloading our Member Application Form using the link provided.

Member Application Form MediCoop Banking Details MediCoop Terms & Conditions Accident Cover Terms & Conditions

Application Type

* South African Citizen / Entity

* Apply as Individual or Business

* Business Type

Individual or Company Information

* ID Number

Business Reg Number

Business Name

* Title

* Initials

* Full Name(s)

* Surname

Nickname

* Marital Status

Spouse Name

Spouse ID Number

Spouse Contact Number

* Cellphone

Telephone

* Email Address

* Gender

* Race

Date Of Birth

Physical Address

* Line 1

Line 2

* Suburb

* City/Town

* Postal Code

Postal Address

* Line 1

Line 2

* Suburb

* City/Town

* Postal Code

Work Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Professional Body Information

Please note that in accordance with the Constitution, each member is required to either belong to a medical professional body or be endorsed by a member of one of these bodies to use their membership number. If you are not a member of one of these bodies yourself, please ensure that the member endorsing you also signs the application form in the allocated area at the end of this application form indicating his/her authorisation of your use of his/her membership number.

HPCSA Number

Practice Number

Other Professional Body or Association Membership Number

Specify Professional Body or Association

Employer / Place of Work

Employer Contact Number

Primary Account Information

Name Of Bank

Branch Name

Branch Code

Account Number

Account Type

Date Opened

Shares and Membership Value

In line with the MediCoop CFI constitution a prospective member is required to purchase a minimum of 1,000 shares (R1 per share) and pay a R200 joining fee in order to qualify for membership.

Number of additional shares required (if any)

Membership and Product Information Newsletters

Where did you hear about us?

* Discovery Media

Source

Consent

* I/we give consent to the process of personal information and allow MediCoop CFI to communicate with/contact me regarding membership information, the affairs of MediCoop CFI, its products and services available to members in terms of the Protection of Personal Information Act 4 of 2013. I/we agree that MediCoop CFI can use your photograph(s) to check your identity and FICA information from the Department of Home Affairs (DHA) and at any other party to confirm any aspect or details of this application. I/we agree to the terms and conditions and confirm that all of the information stated above is correct.
Certain product and services, as marketed on the MediCoop website and in the MediCoop marketing material and brochures are provided through MediCoop’s alliance members. If I select to receive certain product information and related news, and these products and services are provided by the alliance members or 3rd party providers, I/we give consent that MediCoop may send my contact details to the alliance members or 3rd party providers to contact me directly.

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SA Primary Medical Financial Co-operative Limited Registration No. 2015/014609/24 | Registered Credit Provider NCRCP 8712 | Financial Intelligence Centre ID 38406
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