Title: (Optional) None Dr Me Mr Mrs Ms Prof Sr
Name: * Surname: * ID Number: * Phone Number: * Additional Number: (Optional) Email Address: * Choose Province: * Select Province Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga North West Northern Cape Western Cape
Choose Towns/Cities: * Acornhoek Adelaide Alberton Alexander Bay Alexandria Alice Aliwal North Allanridge Amersfoort Ashton Ballitoville Barberton Barkly East Barkly West Beaufort West Bedfordview Benoni Bethal Bethelsdorp Bethlehem Bethulie Bhisho Bloemfontein Bloemhof Boekenhouthoek Boksburg Bonnievale Boshof Bothaville Brakpan Brandfort Bredasdorp Breyten Brits Bronkhorstspruit Buffelshoek Bultfontein Caledon Cape Town Carletonville Carnarvon Casteel Centurion Ceres Cofimvaba Colesberg Cradock Cullinan Daniëlskuil Darling De Aar De Doorns Delareyville Delportshoop Deneysville Despatch Dinokana Doornkop Douglas Dundee Durban Dysselsdorp East London Edenburg Edenvale Ekuvukeni Elandsdoorn eManzimtoti Empangeni eMuziwezinto Ermelo Eshowe Estcourt Evander eXobho Fochville Fort Beaufort Fouriesburg Frankfort Ga-Kgapane Gansbaai Ganyesa Garsfontein George Germiston Gillitts Giyani Glencoe Gonubie Gqeberha Graaff-Reinet Grabouw Grahamstown Greytown Groot-Brakrivier Groutville Hammanskraal Hankey Harding Harrismith Hartbeespoort Hartswater Heilbron Hennenman Hermanus Hertzogville Hillcrest Hopetown Howick Humansdorp Indwe Itsoseng Jan Kempdorp Jeffrey’s Bay Jeppe’s Reef Johannesburg Ka-Bungeni Kakamas Kathu Katlehong Keimoes Kempton Park Khayelitsha Kimberley Kingsborough Kinross Kirkwood Klerksdorp Kloof Knysna Koffiefontein Kokstad Koloti Komatipoort Koppies Kraaipan Kriel Kroonstad Krugersdorp Kuilsrivier Kuruman KwaDukuza Kwamhlanga Ladysmith Langeloop Lebowakgomo Lenyenye Lichtenburg Louis Trichardt Lydenburg Mabeskraal Machadodorp Mahikeng Makan Makapanstad Makwassie Malmesbury Mankoeng Margate Matatiele Mathibestad Mbuzini Meyerton Middelburg Middelburg Midrand Mitchells Plain Mmabatho Mogogelo Mogwase Molteno Mondlo Montagu Mooirivier Moorreesburg Morokweng Mossel Bay Mount Fletcher Mpophomeni Mthatha Musina Namakgale Ncora Nelspruit New Germany Newcastle Nigel Nkowakowa Nqutu Odendaalsrus Okkerneutboom Olifantshoek Orkney Oudtshoorn Paarl Pampierstad Parow Parys Petrus Steyn Phalaborwa Phokeng Phuthaditjhaba Pietermaritzburg Piketberg Pinetown Plettenberg Bay Pofadder Polokwane Port Alfred Port Saint John’s Port Shepstone Postmasburg Potchefstroom Pretoria Pretoria-Noord Prieska Primrose Queensburgh Queenstown Randburg Randfontein Reitz Richards Bay Riebeeckstad Riversdale Robertson Roodepoort Rustenburg Sabie Saint Helena Bay Saldanha Sandton Sannieshof Sasolburg Schweizer-Reineke Scottburgh Secunda Setlagode Sitebe Siyabuswa Somerset East Soweto Springbok Springs Standerton Stellenbosch Steynsrus Stilfontein Stutterheim Summerstrand Swellendam Taung Thaba Nchu Thabazimbi Thohoyandou Tulbagh Turffontein Tzaneen Ubombo Uitenhage Ulundi uMhlanga Rocks Upington Vaal Reefs Vanderbijlpark Vanrhynsdorp Velddrif Ventersburg Vereeniging Villiers Villiersdorp Virginia Volksrust Vrede Vredefort Vredenburg Vredendal Vryburg Vryheid Warden Warrenton Welkom Wellington Wepener Wesselsbron Westonaria Westville Winterveld Witbank Worcester Zeerust

Choose Profession: *
Audiologist Audiometrician Biokineticist Counsellor (registered) Dietician Hearing Aid Acoustician Nutritional Therapist Occupational Therapist Optical Dispenser Optometrist Orthoptist Phlebotomist Physiotherapist Radiographer Social Worker Speech Therapist Dental Assistant Dental Technician Dental Technologist Dental Therapist Dentist General Dental Practitioner Oral Hygienist Oral Pathologist Orthodontist Periodontist Prosthodontist Advanced Life Support (ALS) Ambulance Emergency Assistant (AEA) / Intermediate Life Support (ILS) Bachelor of Emergency Medical Care (BEMC) Basic Ambulance Assistant (BAA) Critical Care Assistant (CCA) Diploma in Emergency Medical Care (Dip EMC) Emergency Care Technician Emergency Care Technician (ECT) Allergologist Anaesthesiologist Anatomical Pathologist Cardiologist Cardio-Thoracic Surgeon Cardio-Thoracic Surgeon Chemical Pathologist Child Psychiatrist Clinical Haematologist Clinical Pathologist Clinical Pharmacologist Colorectal Surgeon Community Health Dermatologist Emergency Care Physician Endocrinologist Environmental Health Practitioner Family Physician Forensic Pathologist Forensic Psychiatrist Gastroenterologist Gastrointestinal Surgeon General Practitioner (GP) General Surgeon Geneticist Geriatric Medicine Specialist Geriatric Psychiatrist Haematologist Hematological Pathologist Infectious Disease Specialist Intensive Care Physician / Critical Care Physician Internal Medicine (Physician) Maxillo-facial and Oral Surgeon Microbiologist Nephrologist Neuro Psychiatrist Neurologist Neurosurgeon Nuclear Medicine Specialist Obstetrician and Gynecologist Occupational Health Practitioner Oncologist - Medical Oncologist - Paediatric Oncologist - Radiation Ophthalmologist Orthopaedic Surgeon Otorhinolaryngologist (ENT) Paediatric Cardiologist Paediatric Endocrinologist Paediatric Gastroenterologist Paediatric Neonatologist Paediatric Nephrologist Paediatric Neurologist Paediatric Pulmonologist Paediatric Surgeon Paediatrician Plastic Surgeon Podiatrist Psychiatrist - General Pulmonologist Radiologist Reproductive Specialist Rheumatologist Specialist Family Practice Sports Medicine Specialist Trauma Surgeon Urologist Vascular Surgeon Virological Pathologist Clinical Psychologist Psychologist Psychometry Registered Counsellor Home-Based Care Nurses Nurses - Assistant/Auxiliary Nurses - Staff/Enrolled Registered Nurse/ Professional Nurse Anatomical Pathologist Blood Transfusion Services Clinical Biochemist Clinical Pathologist Clinical Technologist - Pathologist Clinical Technologist - Pathologist Technician Medical Biological Scientist Medical Geneticist Medical Physicist Medical Technician Medical Technologist Microbiologist Phlebotomist Clinical Pharmacologist Pharmacist Pharmacist Assistant Pharmacologist Pharmacotherapist Biokineticist Occupational Therapist Physical and Sports Medicine Physical Medicine Physiotherapist Sports Medicine Specialist Environmental Health Officer Occupational Health Occupational Medicine Preventive Medicine Specialist Public Health Medicine Cardiology Technician Cardio-Vascular Perfusion Critical Care Technician Nephrology Technician Neurophysiology Technician Pulmonology Technician Reproductive Biology

HPCSA Card Upload (PDF only): * (For Validation) Password: *

Rep Code: (Optional)