COVID-19 Vaccine Form

Please complete this form so that we can better support you through your COVID-19 Vaccine Journey.

All beneficiaries (main members and adult dependants) need to complete this form.

Medical Aid Information

Personal Information

First Name(s) must appear as it is on your ID document
Last Name must appear as it is on your ID document
ID Number must appear as it is on your ID document ID number must be at least 13 characters long
Mobile number must be 10 digits long and start with 0

Where do you want to get vaccinated?

If we know of available vaccination slots at one of our administrator vaccination sites, may we contact you to come through to get vaccinated on short notice (within 1-2 hours)?



Note: You will need to be eligible and registered via EVDS as per the NDoH phase roll-outs.

BY USING THIS WEBSITE AND PROVIDING MY PERSONAL INFORMATION, I CONFIRM THAT I HAVE READ AND UNDERSTOOD THE CONTENTS OF THE PRIVACY POLICY THAT APPEARS AT TERMS OF USE AND CONSENT TO THE PROCESSING OF MY PERSONAL INFORMATION IN TERMS OF THE PROVISIONS OF THE POLICY