COVID-19 Vaccine Form

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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

Do you have medical aid?

Yes
No

Medical Aid Scheme

Medical Aid Number

Medical Aid Plan

Please validate your member number.

Invalid member number or dependant code.

Membership number confirmed.

Medical Aid Dependant Code

This dependant has already registered, do you want to make a booking?

Personal Information

First Name(s) as it is on your ID document

First Name(s) must appear as it is on your ID document

Last Name as it is on your ID document

Last Name must appear as it is on your ID document

ID Type

ID Number

ID Number must appear as it is on your ID document ID number must be at least 13 characters long

Passport Number

Date Of Birth

Gender

Email Address

Mobile Number ex: 0821234567

Mobile number must be 10 digits long and start with 0

Where do you want to get vaccinated?

Suburb

City

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)?

Yes
No

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

I agree to the Terms of Use

You need to be {{currentAge}} or older to register currently

Submitting registration...

Thank you. We have received your information

You have selected to be vaccinated at a Department of Health site, i.e. GP or Pharmacy. When you are eligible and register to be vaccinated (as part of the phased roll-outs) via EVDS, the NDoH will schedule your appointment.

You have selected to be vaccinated at a Medscheme site. Medscheme or its affiliate, Wellness Odyssey, will be in contact to schedule your appointment.

You have selected to be vaccinated at an Employer site. Your employer, if arranging on-site vaccinations, will be in contact to schedule your appointment.

Take note: This form does not replace the National Department of Health (NDoH) Electronic Vaccination Data System (EVDS). When you are eligible to be vaccinated as part of the NDoH phased roll-out plan, go to: https://vaccine.enroll.health.gov.za/#/

Please keep this QR code and bring it along on Vaccination day

To save your QR code, right click on the above image and then select save. You will also receive an SMS with your QR code number

If you are using a mobile device, you can take a screenshot of this screen.

Please click on this button to make your booking

Registration failed. Please verify your details and try again. Ensure that your first name and last name match what is on your ID document.

Registration failed. This ID number has already been registered

Registration failed. This member number has already been registered

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.

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.