Doctors Network Application Form

Day1 Health Doctor Online Application Form

1Doctor Health wishes to identify any willing and able providers to render quality and cost-effective services as non-exclusive designated service providers on behalf of all our clients to members on the 1Doctor Health Options.

Practice Details

Practice Name
Field is required!
Field is required!
Practice Number
Field is required!
Field is required!
MP Number
Field is required!
Field is required!
Field is required!
Field is required!
Do you require us to install Synaxon in your practice (at no cost)?
Field is required!
Field is required!
Are you a Scripting Practice?
Field is required!
Field is required!
Are you a Dispensing Practice?
Field is required!
Field is required!

Physical Address

Street
Field is required!
Field is required!
Suburb
Field is required!
Field is required!
Town
Field is required!
Field is required!
Code
Field is required!
Field is required!
  • - select an option -
  • Eastern Cape
  • Free State
  • Gauteng
  • KwaZulu-Natal
  • Mpumalanga
  • North West
  • Northern Cape
  • Western Cape
- select an option -
Field is required!
Field is required!

Postal Address

Street
Field is required!
Field is required!
Suburb
Field is required!
Field is required!
Town
Field is required!
Field is required!
Code
Field is required!
Field is required!
  • - select an option -
  • Eastern Cape
  • Free State
  • Gauteng
  • KwaZulu-Natal
  • Limpopo
  • Mpumalanga
  • North West
  • Northern Cape
  • Western Cape
- select an option -
Field is required!
Field is required!

Practice Contact Details

Telephone number
Field is required!
Field is required!
Cell number
Field is required!
Field is required!
Fax Number
Field is required!
Field is required!
Email Address
Field is required!
Field is required!

Banking Details

Bank Name:
Field is required!
Field is required!
Account Holder
Field is required!
Field is required!
Account Type
Field is required!
Field is required!
Branch Code
Field is required!
Field is required!
Account Number
Field is required!
Field is required!
VAT Number
Field is required!
Field is required!

Supporting Documents

Cancelled Cheque Or Stamped Bank Letter
Field is required!
Field is required!
Proof of Practice physical address
Field is required!
Field is required!
BHF Registration Confirmation
Field is required!
Field is required!
ID Document
Field is required!
Field is required!
HPCSA Registration Confirmation
Field is required!
Field is required!
License to Dispense
Field is required!
Field is required!