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Get Your Medical Aid Quote

Complete the form below to request a personalised KeyHealth medical aid quote. Fields marked with * are required.

Your name and surname*

Your date of birth*

Email address for your quote*

Contact number for your quote*

Your province*

Will your quote include a spouse?
No Yes

Number of children under 21 to include in the quote

Number of children aged 21–27 who are studying

Number of children aged 21–27 who are not studying

Previous medical scheme details for your quote

I have no previous medical aid

NAME OF MEMBER	NAME OF SCHEME	MEMBERSHIP NUMBER	DATE JOINED	DATE TERMINATED

Are you changing your medical scheme because of a change in employment? If yes, please provide proof of the change in employment. (Closed Scheme members only) Yes No

Medical details for your quote

FAILURE TO DISCLOSE PRE-EXISTING CONDITIONS COULD LIMIT AND/OR EXCLUDE CERTAIN BENEFITS OR RESULT IN TERMINATION OF YOUR MEMBERSHIP

To help us prepare an accurate quote, did you or any of your dependants have any of the following operations, medical conditions or disorders during the past 12 months or received treatment, advice and/or medication for any of them. Please tick "Yes" or "No"

1. Diabetes, Heart Disease, Stroke, Cancer, Irregular menstruation cycle/abnormal menstrual bleeding, Hypertension and Cholesterol? *

Yes No

2. Taking medicine on an on-going basis or reasonably expecting to take medicine in the next 12 months? *

Yes No

3. Had any operations or admission to any hospital in the last 12 months? *

Yes No

4. Awaiting or planning any operation or admission to hospital (including pregnancy) for treatment in the next 12 months? *

Yes No

5. Is there any other condition or symptom, not detailed in any question above, for which medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical claim within 12 months? *

Yes No

Additional information for your quote

How did you hear about KeyHealth Medical Scheme?

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