Medshield Medical Aid Quote

Should you wish to get an idea of what a Medshield medical aid will cost, please complete the blocks below and send to me.
I will send you costs, based on your plan selection - no obligation at all.

GOTO MEDSHIELD MEDICAL AID for full details.

Your Details

Do you have to join your company medical aid scheme or can you choose a scheme?
Company scheme
Own

Your email address:
Your telephone/cell number:
Your name and surname:
Your Date of Birth:
Your partner's name and surname (if required):
Your partner's Date of Birth:
First child's name:
Child's Date of Birth:
Second child's name:
Child's Date of Birth:
Third child's name:
Child's Date of Birth:
Any OTHER (NOT ALREADY STATED ABOVE) dependants - adults or children you want to add?

Any other information we should know about?

Your current medical aid plan (if any): Please state the actual plan as well.

Would you like to receive my informative letter on personal financial matters? Yes

Please note:

• The submission of this request does not constitute any legal obligation, either on your or Peter J Pyburn's behalf.
  It is simply a request to get some medical aid options.
• All information provided will be strictly confidential at all times and will be freely transmitted to the email address provided.
  Peter J Pyburn will not be responsible should the information be incorrectly transmitted or not reach the correct recipient.
• Your email address will never be given to any other person or organisation.
  (I would never be in business if this happened!)
• YOU MUST CONSULT THE SCHEMES BROCHURES FOR COMPREHENSIVE BENEFIT DESCRIPTIONS AND CONSULT THE SCHEME DIRECTLY FOR ANY UNDERWRITING CONCERNS.
• AT ALL TIMES, THE SCHEME RULES WILL OVERRIDE ANYTHING PETER J PYBURN HAS SAID OR WRITTEN AND AS SUCH YOU AGREE WITH THE DISCLAIMER AS PRESENTED IN THE QUOTE/S YOU HAVE ACTED UPON.

I confirm that I have read and understood the notes above. Yes

pyburn@peterpyburn.co.za