Intermediary Instruction Page - Link Pharmacy

If you experience any problems, please click here to send us your contact details so that we can try and rectify the situation.

Intermediary details

Intermediary Code: Parent:
Name: Surname:
Email Address:

Client Details

Title:
Name: Surname:
Contact Number: Alt. Number:
Email Address:
Is your customer currently on a medical scheme? If yes, please provide the name of the medical scheme:
Additional Information:
Province:

Protection of Personal Information Act (POPIA) Declaration
By providing the information in this form on behalf of your client, consent is given to our fulfilment partner to establish contact in order to provide the necessary advice. Your client’s personal information will be stored in a secure encrypted manner and will not be sold or disseminated to any third party without their explicit consent.

Please select desired outcome

More Info
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Are you currently on a medical scheme?
If Yes, which Scheme and Option:
I have been a member since:
Do you currently have a Health Care Broker?
What is your family size?
Adults Children

Provide us with your family`s ages:
Principal Spouse
Adult Dependent
Child 1 Child 2
Child 3 Child 4
Do you or your dependants use any chronic mediation?

Do you want cover for day-to-day expenses? (eg. GP`s, Dentists, X-rays)
Gross Income per month for Main Member?



Gross Income per month for Spouse?



Can we provide you with information regarding GapCover?

Notes for specific requirements:
Can we send you future communication on related news and products?

Protection of Personal Information Act (POPIA) Declaration
By providing the information in this form on behalf of your client, consent is given to our fulfilment partner to establish contact in order to provide the necessary advice. Your client’s personal information will be stored in a secure encrypted manner and will not be sold or disseminated to any third party without their explicit consent.

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