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

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!
Are you a Scripting Practice?
Field is required!
Are you a Dispensing Practice?
Field is required!

Physical Address

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

Postal Address

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

Practice Contact Details

Field is required!
Field is required!
Field is required!
Field is required!

Banking Details

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!

Supporting Documents

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

Create your account