FAX Transmission
To: Metropolitan Health Group Pages: 1 of 1
Fax: (021) 480 4087 Date:
Phone: (021) 480-4511    
Subject: Service Provider Application for Personal Identity Number
INSTRUCTIONS: Print1. Click here to Print this form
2. Complete all required details
3. Fax the completed form to the fax number specified above.

Full Name:  
Address:  
   
   
E-mail:  
Cell Number:  
Practice Number:  
4 Digit PIN:  
Comments:  
   
   
   


NOTES: The Metropolitan Health Group will reply to you (via e-mail if possible) as soon as your number/PIN combination has been activated, and you can enjoy 24 hour real time access to your own information.




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