Register

Please fill out the form to register

Practitioner Name: *

First

Last

ID No:

Practice Name: *

Multi-doctor Practice (Yes/No)? *

Practice / BHF Code: *

HPCSA No.: (attach copy) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Google Maps - Location

1) Open Google Maps 2) Find your practice location - zoom in and click on it. A small pop-up box opens at the bottom of window. 3) Click on the 'share' icon 4) "COPY LINK" -> Insert/Paste into the field above here

Contact Person: *

Phone *

Phone 2

Email *

Email 2

Confirmation of Service Provision: *

We confirm that we wish to provide this service and RECEIVE a pick-up-point service fee:
We confirm that we wish to provide this service but we wish to NOT RECEIVE a pick-up-point service fee:

The following banking details will allow KERA to remit earned fees directly into the preferred recipient bank account (South Africa based accounts only). All Fields Required / Only For Fee-Accepting Practices As Per Above Confirmation. Banking details will not be shared with any 3rd parties

Bank:

Account Name:

Account Type:

Account Number:

Branch Name / Number:

Copy of HPCSA License (applicant practitioner):

Drag & Drop Files, Choose Files to Upload

No.: (attach of

Copy of ID (applicant practitioner):

Drag & Drop Files, Choose Files to Upload

Copy of Cancelled Page from Script Pad (practice):

Drag & Drop Files, Choose Files to Upload