Pre-Qualification Form
Please complete the questionnaire below to ensure you qualify to use our telemedicine platform before you are registered. 
Email *
Full Name *
City/Town *
Phone Number *
Are you comfortable using technology and navigating digital platforms?  *
Required
Have you used other Telemedicine platforms and Electronic Health Record (EHR) systems before?  *
Required
What is your HPCSA number?  *
What is your medical specialty or area of expertise?  *
Are you registered with the Board of Healthcare Funders (BHF)?  *
If you are, what is your BHF practice number? 
If not, would you need our assistance with the registration to the BHF? 
Clear selection
Is your medical practice registered with the various medical aid schemes?  *
If not, would you need our assistance with the registration to the various medical aid schemes? 
Clear selection
Do you have medical indemnity insurance?  *
If not, would you need our assistance with finding suitable insurance options? 
Clear selection
Which of our pricing plans best suits your practice’s current needs? *
How did you hear about us?  *
Do you consent to Prime Virtual Care verifying the professional and registration information you have provided in this form? *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms