Practitioner Details

*Compulsory to complete - for a successful listing

*First Name:

*Surname:

*Professional Degrees:

*Professional Body Memberships:

*HPCSA Number:

*Board of HealthCare Funders PCNS Number:

DOH Disp Lic Number (if applicable):

Areas of Special Interest:

About Practitioner:

Contact Details

*Contact Number (Practice):

*Email Address:

*Alternative Number:

Fax Number:

Practice Details

*Practice Name:

Group PCNS:

*Practice Address:

GPS Location:

In order to improve your practice exposure, you may also provide: (not compulsory)

Photo of yourself - so that the patient can familiarize themselves with the Dr they are going to see.

Photo of the outside of the Practice - so the patient will recognize the correct building and know what to look out for when coming to visit the practice.

A short bio - interests, hobbies & education - this gives the patient further trust as they will feel they know you and will feel at home.

If you have any questions, please feel free to contact Anneré van Pletsen our CPC/Qualicare Consultant at annere@cpcqualicare.co.za

Logo:

Practice Image:

Doctor Image:

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