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Personal Information

Practice Details

In the last 10 years

  • Personal
  • Practice
  • History

Personal Information


First Name



ID Number

Email address


Practice Details

HPCSA number

Practice Type

How is your time spent in your professional capacity?

Are you a member of any association, professional body or registered with any self-regulating organisation?

Do you currently have medical malpractice or professional indemnity?

If Yes, please provide name of insurer, policy number and level of cover e.g R10M

Is the cover for claims made or occurrence based cover?

In the last 10 years

Have you ever received a complaint arising out of your professional practice?

Have you ever had an incedent reported to the HPCSA , hospital committee or any regulatory body?

Have you had any disciplinary action taken by the HPCSA , hospital committee or any regulatory body?

Do you have any current, pending or prior legal action relating to your professional practice?