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BECOME AN AFFILIATE

Please complete the following form (or download the pdf) with all your details to apply to join the LifeAssist Affiliate network. We look forward to working with you!

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Affiliate Name: *

Your Qualifications: *

Registration Number (HPCSA) *

BHF/Practice number: *

Email Address *

Website: (If applicable)

Contact Number: *

Alternate Contact Number

Your Practice:

Physical Address:

City:

Province:

Service areas within 20km’s of your practice:

Place of practice e.g. office / private home? *

Is your practice easily accessible? *

Yes No

Do you have safe and sufficient parking available? *

Yes No

Do you have a waiting / reception area? *

Yes No

Do you have a receptionist? *

Yes No

Are you computer literate? *

Yes No

Do you have internet access? *

Yes No

Do you have access to external resources / support services? *

Yes No

If yes, please list and describe these:

Account details:

Bank Name:

Account Name:

Account Number:

Branch Code:

Account Type (Cheque/Savings):

Languages:

Home Language:

Additional languages:

Speak

Read:

Write:

Additional languages:

Speak

Read:

Write:

Additional languages:

Speak:

Read:

Write:

Preference of Work:

Adults:

Yes No

Children:

Yes No

Couples:

Yes No

Groups:

Yes No

Are you prepared to travel?

Yes No

Onsite Clinic:

Yes No

Areas of Speciality / Interests:

Thank you:

Thank you for taking the time to complete this form. We will be in contact with you shortly.

Any additional information:

Information Summary

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OUR SERVICES

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Get in touch with LifeAssist! We look forward to hearing from you.

Phone: +27 (0) 11 912 1000

EMAIL US ON:

General enquiries: info@lifeassist.co.za
(THIS IS CORPORATE CONTACT INFORMATION. IF YOU ARE AN EXISTING CLIENT AND WOULD LIKE A REFERRAL, PLEASE SPEAK TO HR TO OBTAIN YOUR PROGRAMME CONTACT DETAILS.)

Marketing enquiries: marketing@lifeassist.co.za
New affiliate accreditation: affiliates@lifeassist.co.za

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