Medical Aid - Manual
New Leads Capture Form
Personal Details
Title
Dr
Miss
Mr
Mrs
Ms
Prof
Rev
Past.
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First Name
*
Second Name
Last Name
*
Phone
*
Email
Date of birth
ID Number
Organization
Department/Unit Name
Medical Aid Plan Preference
Comprehensive - Hospital & Day to Day Cover
Hospital Plan Only
Affordable Network Plan
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What is Your Current Medical Aid?
Not On a Medical Aid Currently
BankMed
BCIMA
BestMed
Bonitas
CAMAF
Cape Medical Plan
CompCare
Discovery Health
FedHealth
GEMS
Genesis
Imperial Motus Medical Aid
KeyHealth
LA Health
Makoti
MediHelp
MedShield
Momentum Health
MotoHealth
ProfMed
Remedi
Sabmas
Samwumed
Sisonke
Sizwe Hostmed
SureMed
ThebeMed
Umvuzo
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Add Spouse?
Yes
No
Add Child Dependants? (under 21 years)
Yes
No
How Many Children?
1
2
3
4
5
6
7
8
9
10
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Which Pre-existing Condition/s Do You Have?
Add Adult Dependants? (over 21 years)
Yes
No
How Many Adults Dependants?
1
2
3
4
5
6
7
8
9
10
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Add Parent Dependants?
Yes
No
How Many Parents?
1
2
3
4
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Do You Or Any Of Your Dependants Have A Pre-existing Illness?
Yes
No
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Are You Or Any Of Your Dependants Pregnant?
N/A
Yes
No
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Do You Or Any Of Your Dependants Have A Chronic Condition?
Yes
No
What is a Chronic Condition?
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Which Chronic Condition/s Do You Have?
Addison’s Disease (PMB)
Asthma (PMB)
Bipolar Mood Disorder (PMB)
Bronchiectasis (PMB)
Cardiac failure (PMB)
Cardiomyopathy (PMB)
Chronic Obstructive Pulmonary Disease (COPD) (PMB)
Chronic Renal Disease (PMB)
Coronary Artery Disease (PMB)
Crohn’s Disease (PMB)
Diabetes insipidus (PMB)
Diabetes type 1 (PMB)
Diabetes type 2 (PMB)
Dysrhythmia (PMB)
Epilepsy (PMB)
Glaucoma (PMB)
Haemophilia (PMB)
HIV (PMB)
Hyperlipidaemia (PMB)
Hypertension (PMB)
Hypothyroidism (PMB)
Multiple Sclerosis (PMB)
Parkinson’s Disease (PMB)
Rheumatoid Arthritis (PMB)
Schizophrenia (PMB)
Systemic Lupus Erythematosus (PMB)
Ulcerative colitis (PMB)
Ankylosing spondylitis (ADL)
Behcet’s disease (ADL)
Cystic fibrosis (ADL)
Delusional disorder (ADL)
Dermatopolymyositis (ADL)
Generalised Anxiety Disorder (ADL)
Huntington’s Disease (ADL)
Isolated Growth Hormone Deficiency in Children Younger Than 18 years (ADL)
Major Depression (ADL)
Motor Neurone Disease (ADL)
Muscular Dystrophy & Other Inherited Myopathies (ADL)
Myasthenia Gravis (ADL)
Obsessive Compulsive Disorder (ADL)
Osteoporosis (ADL)
Paget’s Disease (ADL)
Panic Disorder (ADL)
Polyarteritis Nodosa (ADL)
Post-Traumatic Stress Disorder (ADL)
Psoriatic arthritis (ADL)
Pulmonary Interstitial Fibrosis (ADL)
Sjögren’s Syndrome (ADL)
Systemic Sclerosis (ADL)
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