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Request Registration Form:
Please Note:
There is a R300 Registration fee, which is required before your account will be activated. A consultant will contact you after registration to discuss payment methods.
* Fields In red indicate required fields
Registration Type
Locum
Locum Host
Title
Dr.
Mr.
Prof.
Initials
First Name
Last Name
Discipline
Anaesthetist
Cardiologist
Dentist
Ear, Nose & Throat
General Practitioner
Gynaecologist
Occupational Therapist
Oncologist
Optometrist
Paediatrician
Physiotherapist
Physician
Psychiatrist
Psychologist
Speech Therapist
Urologist
Other....
Practice Number
SAMDC Number
Email Address
Postal Address
Cell/Mobile Number
Home Number
Work Number
Alternate Number
N/a
Special Requirements
Notes
