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Client registration form

Personal details

First Name*

Last Name*

E-mail*

Password*

Confirm Password*

Mobile No.*

Date of Birth

Acceptable Use Policy*

I have read and accept the Acceptable Use Policy

Privacy Policy*

I have read and accept the Privacy Policy

Client Agreement*

I have read and accept the Client Agreement

Gender

MaleFemale

City*

Emergency Contact Name

Emergency Contact No.

Medical aid details

Medical Aid Communications Consent

I hereby grant Headroom permission to communicate directly with my medical aid in case of queries. I acknowledge that the responsibility to submit my claims is mine.

Medical Aid Membership No.

Medical Aid Name

Dependent Code

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Client Agreement

Privacy Policy

Acceptable Use Policy

If you are in a life threatening situation – do not use this site! Call +911 or use these resources to get immediate help.

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