Alternatively download the PDF here which you can print and fill out. Once completed, you can email it to reception@vidamed.co.za.
Name of doctor
Practice number
ICD code
Procedure
Date of procedure
Surname
Full names
ID nr
Occupation
GenderFemaleMale
LanguageAfrikaansEnglish
Cell nr
Email address
Copy of IDAllowed types: jpg, png, pdf.
Copy of Fund CardAllowed types: jpg, png, pdf.
Medical fund
Option
Member nr
Patient dependent code
Main member name and surname
Main member ID nr
Physical address
Name
Relationship to patient
