Free Selfmed Medical Aid Quote

Should you wish to get an idea of what an Selfmed medical aid will cost, please complete the blocks below and send to me.
A professional consultant from Selfmed will then call you - no obligation at all.

Your Details

Do you have to join your company medical aid?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:
Any OTHER Adult dependant's - if so, how many?
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 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!)

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

pyburn@peterpyburn.co.za