Patient Information Form

Please fill out the form below:

Click here to download the pdf version of the form below

Main Member Details

 

Address Details

 

Patient Details

Each patient receiving medication must be listed in this section

 

Ordering Method

 
Do you and your doctor agree to the use of generic medicine for your prescription?
 
In the event that my Medical Scheme fails to pay for the medication supplied to me and my dependants by Medipost, I confirm and acknowledge that I as the principal member will remain responsible for the payment to Medipost who are entitled to seek payment from me for any amount not paid by the Medical Scheme on my behalf.

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