Consultant: Wynand Louw
Date: 16 May 2025

PRIMARY HEALTHCARE – INFO GATHERING & NEEDS ANALYSIS

Title
Initials
Surname*
ID / Passport Number*
Date of Birth*
Email*
Mobile
Work
Marital Status
Gender
Nationality
Citizenship
Residential Address
Postal Address
Employer
Occupation
Gross Salary R
Subsidy R
Source of Income
Source of Wealth
Number of Dependants Adults Spouse Children
Age of Dependants Adults Spouse Children
Current Medical Scheme
Current Primary Healthcare Plan

Review medical scheme

Review primary healthcare plan
Chronic Conditions

Choose Conditions

Medication
Other Medical Conditions
Hospital Care Primary Care Hospital Care & Primary Care
Need Need Identfied Comments or Details
Yes No
Illness & Accidental cover
Accidental Only
Hospital Cover
GP visits
Specialist visits
Prescribed & chronic medication
Dentristy
Optometry
Maternity
Other

[Indicate whether a new primary healthcare plan is recommended or an existing policy is to be replaced]

See comparison attached Yes No
New Primary Healthcare Policy
Replace Primary Healthcare Policy
Replace Medical scheme
Broker Appointment
Preferred Communication
Consent to receive the following. Newsletters Product and industry-related updates
Information about complementary services and products Further processing of personal information, for example, quality assurance.