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RAF ONLINE SERVICE PROVIDER REGISTRATION
Practice Details
Banking Details
Contact Person Details
Practice Name
*
Practice Type
Please Select
Medical Service Provider
*
Practice Number
*
HPCSA Number
*
CIPC Number
Is your practice VAT registered?
Yes
No
VAT Number
*
Tax Reference Number
*
Service
Medical Services
*
Field of expertise
AMA trained medical practitioners
Cardiothoracic surgeon
Child Psychologist
Clinical psychologist
Dentist
Dermatologist
Ear, Nose and Throat Specialist
Educational psychologist
Endocrinologist
Gynecologist
Industrial psychologists
Maxillo Facial and Oral Surgeon
Neurologist
Neuropsychologist
Neurosurgeon
Occupational Therapist
Ophthalmic Surgeon
Orthodontists
Orthopedic surgeon
Other Experts
Pediatrician
Physiotherapist
Plastic and reconstructive surgeon
Plastic surgeon
Psychiatrist
Radiologist
Specialist Physician
Speech Therapist
Urologist
Vascular Surgeon
*
Province(s)
Eastern Cape
Free State
Gauteng
Kwazulu Natal
Limpopo
Mpumalanga
North West
Northern Cape
Western Cape
*
Professional Body
HPCSA
*
Telephone
*
Email
*
Physical Address
*
Postal Address
*
Next
Bank Name
*
Branch Name
*
Account Type
Please Select
Cheque
Other
Savings
*
Branch Number
*
Account Number
*
Name of Account Holder
*
Account Holder ID/Practice Number
*
Next
First Name
*
Surname
*
Identity Number
*
Cell Number
*
Telephone (H)
Telephone (W)
Fax Number
Email Address
*
Postal Address
*
Physical Address
*
Register
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