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Online applications for membership are included on this website for your convenience. Please take a few moments to complete all the applicable sections in full. We will process your application and contact you within 48 hours.
 
Please make sure that all fields are filled out properly. Invalid form values
will be displayed in red (marked with *).
 
Application for membership
 
Benefit Option:   Required date of membership:
 
Status of applicant:  
Principal Member  
Additional Dependant
Special Dependant
Are you applying as a Private Member?  
Or as a member of an Employer Group?
Particulars of Principal Member
 
Title:  
 
 
 
  Work Tel:
(Code & No.)
 
 
Postal
Address:
 
Sex:
Male Female Are you a pensioner? Yes No
 
 
 
Occupation:   Income:
 
Employment Details
 
Name of Company:   E-Mail:
 
Tel:
(Code & No.) 		  Fax:
(Code & No.)
 
Postal
Address:
 
Particulars of Previous Medical Cover
 
Are / were you a member / Dependant of a
registered medical aid fund for the past 2 years?		 Yes No
 
Name of present Medical Aid Fund:
Membership Number:
 
Period of membership:  
From:
To:
 
 
Name of previous Medical Aid Fund:
Membership Number:
 
Period of membership:  
From:
To:
 
Particulars of Dependants
 
Husband, wife and children under 21 years who are unmarried and not in full time employment. Children up to 25 years may be included if they are financially dependant and full time students at an educational institution.
 
Dependent: Spouse
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
Dependent: 1st Child
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
Dependent: 2nd Child
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
Dependent: 3rd Child
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
Dependent: 4th Child
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
Dependent: 5th Child
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
Dependent: 6th Child
 
First Names:   Surname:
 
Occupation:   Sex M / F:
 
Date of Birth DD / MM / YY:
 
State of Health
 
Have you, your spouse or any of your dependents ever experienced any of the following:
 
1. Any disorder of the heart eg. angina, heart attack, heart murmur, rheumatic fever, coronary artery disease, chest pain, shortness of breath, palpitations.
Yes   No  
 
2. High blood pressure or disease of the blood vessels or circulatory disorder?
Yes   No  
 
3. Any respiratory or lung disease/disorder eg. asthma, bronchitis, tuberculosis?
Yes   No  
 
4. Any disorder of the digestive system, gall bladder, pancreas or liver?
Yes   No  
 
5. Disease or disorder of the kidneys, bladder or reproductive organs?
Yes   No  
 
6. Diabetes, thyroid or other glandular or blood disorders, eg. leukaemia, haemophilia?
Yes   No  
 
7. Eye, ear, nose or throat disorder, eg. defective vision, hearing loss, glaucoma?
Yes   No  
 
8. Nervous or mental complaint, eg. epilepsy, blackouts, paralysis, fits, multiple sclerosis?
Yes   No  
 
9. Disorder or disease of the skin, muscles, bones, joints, limbs or spine?
Yes   No  
 
10. Any tropical disease, eg. bilharzia, malaria, brucellosis?
Yes   No  
 
11. Cancer, a growth or tumor of any kind?
Yes   No  
 
12. Any other illness, disorder or operation, disability or accident?
Yes   No  
 
13. Any physical abnormality, deformity, handicap or defect?
Yes   No  
 
14. Are you currently undergoing or expecting to undergo any medical, dental or surgical treatment?
Yes   No  
 
15. Medical advice, counselling, treatment or blood test for AIDS or an AIDS-related condition?
Yes   No  
 
16. Are you or any of your dependants pregnant? If yes state expected date of confinement.
Yes   No  
 
17. Has your weight changed by more than 5kg in the last 12 months?
Yes   No  
 
18. Height and weight:
Height and weight (principal member):
Height:   Weight:
 
Height and weight (spouse):
Height:   Weight:
 
19. Does any of your immediate family suffer from diabetes, heart disease, high blood pressure?
Yes   No  
 
If you have answered yes to any of the above questions, please complete details below in full:
 
Chronic Medication
 
Do you or any of your dependents use chronic medication?
Yes   No  
 
Beneficiary:   Illness:
 
Period Medication Used
From:
DD/MM/YY		   To:
DD/MM/YY
 
 
Beneficiary:   Illness:
 
Period Medication Used
From:
DD/MM/YY		   To:
DD/MM/YY
 
 
Beneficiary:   Illness:
 
Period Medication Used
From:
DD/MM/YY		   To:
DD/MM/YY
 
Undertaking by Applicant
 
Thank you for taking the time to complete this online application form. By clicking the 'Send Application' button you are agreeing to the terms and conditions below:

1. I apply for membership of the Renaissance Health Medical Aid Fund and agree that all answers and information contained in this application shall be the basis of my membership and that it shall be warranted as true and complete; and that my membership shall be void if any information should be inaccurate or incomplete, in which event all moneys paid towards the membership shall be forfeited to Renaissance Health Medical Aid Fund, and that all benefits paid shall be immediately repayable to Renaissance Health Medical Aid Fund.

My membership shall not commence unless Renaissance Health Medical Aid Fund specifically notifies me in writing of their acceptance of the risk; and any deterioration or change of the state of my health or the health of my dependants before the date or before the date or the occurrance set by Renaissance Health Medical Aid Fund for the commencement of the membership or the date on which this application is accepted by Renaissance Health Medical Aid Fund, or the date of receipt of the first subscription whichever is the latest date, shall give Renaissance Health Medical Aid Fund the right to reconsider the application and to propose new terms of acceptance or to declare the membership null and void in which event all moneys paid toward this membership before Renaissance Health Medical Aid Fund receives notice of such a change will be forfeited to Renaissance Health Medical Aid Fund and benefits paid shall immediately be repayable to Renaissance Health Medical Aid Fund.

2. I irrevocably give my consent to my medical doctor, person or organisation, who may posess, or may come in possession of any information regarding my health or the health of my dependants, to disclose this information to Renaissance Health Medical Aid Fund, also after my death.

3. I give my consent to my employer in the case of group membership to deduct from my salary and pay Renaissance Health Medical Aid Fund all amounts that may be due by me to Renaissance Health Medical Aid Fund.
 
 
 
 
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