Membership Waiting List

Note: This form does not create a doctor–patient relationship and is not for urgent issues.

Who is this application for?

Myself Myself + partner My whole family My organisation / employer / embassy

Name

Year of Birth

Email Address

Mobile Number

City / Area of Residence

Preferred Contact Method

Phone call Email SMS / WhatsApp Any method is fine

How many adults?

How many children?

Children’s Age Groups (Select all that apply)

0–5 6–12 13–17 18–26

Would you like us to recommend the best option?

Yes, please No, I already know what I want

Which membership are you interested in?

Premium
Advanced diagnostics, MRI/Dexa, unlimited access

Family
Complete care for children and adults.

Not sure — please advise me

When would you like to start?

Which services matter most to you? (Select all that apply)

How did you hear about us?

Do you have private health insurance?

Yes No Not Sure

Have Code?