PHONEDOC APPLICATION FORM

Thank you for your interest in Phonedoc. We hope that you, your family and loved ones are keeping safe and healthy at these unforeseen times. We would like to invite you to complete the application form below supplying the correct and accurate information, for consideration in being part of Phonedoc.
Name

First NameMiddle NameSurname
Home Address
Title

DrProfMrMs
Postal Address
ID Number:
Email Address
example@example.com
Cell Phone No

Area CodePhone Number
Healthcare Professional Category

General PractitionerSpecialistPsychologistDieticianNursePhysiotherapist
Qualifications
University
Year Graduated
HPCSA/Registration No
MPS Number
Is the MPS coverage current?

YesNo
Have you had any Medical Claims against your name?

YesNo
If yes, please explain
Are there any pending Litigation or Medical Claims?

YesNo
If yes, please explain
Do you have Professional Indemnity Cover?

YesNo
If yes, with who?
What is your PIC Policy Number?
What is the limit of your liability cover?
Name of Broker
Contact number of Broker
Email address of Broker
example@example.com
Years of Service
Post Community Service
Weekday Hours Available
Weekend Hours Available
Do you have a Practice Number with BHF/PCNS that is valid?

YesNo
Which Smartphone do you own?

AppleAndroidNone
How did you hear about Phonedoc?

FacebookLinkedinGoogleColleagueOther
Languages spoken fluently
I agree that the above information provided is true, accurate & correct. I understand that should any of the above information provided, is found to be untruthful or factually incorrect, that this would immediately disqualify this application process.
Signature
Date

MonthDayYear
Date
Checklist

Identity DocumentHPCSA Certificate of RegistrationProfessional IndemnityCurrent HPCSA Registration CardLetter of Good Standing or Reference LetterBHF Number (optional)Other
Identity Document

Browse Files

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HPCSA Certificate of Registration

Browse Files

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Professional Indemnity

Browse Files

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Current HPCSA Registration Card

Browse Files

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Letter of Good Standing or Reference Letter

Browse Files

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BHF Number (optional)

Browse Files

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Phonedoc strives to deliver telephone quality healthcare in South Africa. As such, we have a fierce vetting process and all required fields have to be completed. All telephone consultations between doctors and patients would be recorded and would be able to be retrieved should there be any conflict in medical advice offered and for process management purposes.

Payment for each call completed consultation would be R150.00 for General Practitioners and R250.00 for Specialists. There is no prescribed minimum or maximum duration of call required, provided the patient has received adequate professional medical advice attention.

We are always cognisant of HPCSA guidelines for telemedicine and will ensure that our professional services are kept current and relevant at all times, abiding by HPCSA Rules and Regulations at all times. We look forward to your completed application form and if successful in this process, we look forward to welcoming you onboard the Phonedoc Team, as we aim to launch soon. Successful candidates would be sent a copy of the Service Level Agreement (SLA) to confirm your employment contract with Phonedoc. A recent Letter of Good Standing within the past three months from HPCSA would be advisable.
Internal Departmental Use:
Applicant Info Verification Complete
Outstanding Information Required
Inform Applicant of Application Outcome
Email response sent to Applicant & Date
example@example.com
Service Level Agreement Sent to Applicant
Response from Applicant & signed Service Level Agreement
Phonedoc (PTY) Ltd. Registered Company Number: 2021/303716/07, Address: 7 Floor Mandela Rhodes Place, Corner Wale Street and Burg Street, Cape Town, Western Cape, South Africa, 8000. Phonedoc: V01/F01
Should be Empty:

Internal Departmental Use: