Pfumvudza Application Page - Global Health Medical Aid Service

Fill in the application form to start your journey to a healthier life with us.

1 Contact Details

2 Personal Details

3 Banking Details

4 Medical Scheme

5 Dependants Information

Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
Marital Status*
ID Number
Weight (KGs)
Please enter a number from 20 to 400.
Height (m)
Please enter a number from 0.5 to 2.5.
Occupation*
File
Accepted file types: jpg, gif, png, pdf, doc, docx, rtf.
Upload a Passport Size Photo Here

Bank*
Branch Code*
Account Name*
Account Number*
Have you been a member of any medical aid in the past ?*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Society*
Number*
Scheme*
Please attach a certificate of membership from your previous medical aid society.*
Accepted file types: jpg, gif, png, pdf, doc, docx, rtf.
GHMAS reserves the right to waiver or impose waiting periods against a certificate of membership.

Dependant 1
Surname*
First Name(s)*
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
ID Number*
Weight (KGs)
Please enter a number from 2 to 400.
Height (m)
Please enter a number from 0.5 to 3.
Relationship to Principal Member*
File
Accepted file types: jpg, gif, png, pdf, doc, docx, rtf.
Upload a Passport Size Photo Here

Dependant 2
Surname*
First Name(s)*
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
ID Number*
Weight (KGs)
Please enter a number from 0.5 to 400.
Height (m)
Please enter a number from 0.5 to 3.
Relationship to Principal Member
File
Accepted file types: jpg, gif, png, pdf, doc, docx, rtf.
Upload a Passport Size Photo Here

Dependant 3
Surname*
First Name(s)*
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
ID Number*
Weight (KGs)
Please enter a number from 0.5 to 400.
Height (m)
Please enter a number from 0.5 to 3.
Relationship to Principal Member*
File
Accepted file types: jpg, gif, png, pdf, doc, docx, rtf.
Upload a Passport Size Photo Here

Dependant 4
Surname*
First Name(s)*
Date of Birth*
Date Format: DD slash MM slash YYYY
Gender*
ID Number*
Weight (KGs)
Please enter a number from 0.5 to 400.
Height (m)
Please enter a number from 0.5 to 3.
Relationship to Principal Member*
File
Accepted file types: jpg, gif, png, pdf, doc, docx, rtf.
Upload a Passport Size Photo Here