ASAIPA - Full Membership Sign up
Member Information
First Name:
Initials:
Surname:
SA ID No:
Date of Birth:
Gender:
Male
Female
Race:
Black
White
Coloured
Asain
Indian
Other
Preferred Language:
English
Afrikaans
Email:
HPCSA No:
Cell Phone:
(Cell no. preferred for notification SMS's)
IPA:
Please Select an IPA
Medical Profession:
General Practitioners
Practice Information
Practice No:
Practice Name:
Physical Address
Postal Address
Address Search:
Same as Physical?
Building Name & Description:
Physical Address:
Postal Address:
Suburb:
Suburb:
Code:
Code:
Group Practice No:
(optional)
Practice Email:
Practice Tel No:
Emergency Tel No:
Debit Order Information
Account Name:
Account Type:
Cheque
Savings
Transmission
Account Number:
Bank Name:
Please Select a Bank
Branch Code:
Debit Order Merch Code:
Debit Order Amount:
Please enter the letters displayed:
Yes I agreed with the
Terms and Conditions
View
Privacy Policy here
Submit
Additional information and forms will be emailed to you in order to complete the membership sign-up process.
SignFlow Asaipa Form of Undertaken will be mailed to be electronically signed.
Once Signed system actived your contract.
Confirmation SMS will be sent to you.