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Membership Application Form

    Co-Members included

    MONTHLY MEMBERSHIP FEES

    Please note fees increase on the 1st of April 2024 for all members.

    Household Membership : R375 per household p/m. By submitting this form you are applying for CMR Membership which includes the cost of the CMR’s rapid advanced life-support paramedic response service and any treatment and medical consumables used in treatment.
    Do you want CMR Ambulance Transport Cover at R160 per household p/m? If you select not to take this cover the cost of the ambulance transport is not included.

    IF MORE THAN 6 PEOPLE NEED COVER AT THE PROPERTY INDICATE BELOW HOW MANY TO ADD AT AN ADDITIONAL COST OF R75 PER PERSON

    Membership for Domestic workers who live off the property @ R75 p/person p/month

    Please email their name, date of birth and phone number to lisa@cmr-med.co.za or make use of the co-members field above if you have their details to hand now.

    B&B Beds @ R50 p/Bed p/month

    Start date of membership

    Immediate cover. I agree to pay pro-rata for the joining month by once-off debit on the date of commencement of this membershipPlease contact me to discuss a different start date and/or a different payment method for the first month.

    Notes

    Person responsible for account

    Cheque/CurrentSavings

    Preferred debit date

    1st of month15th of month

    By submitting this form, I/we agree to subscribe to the service in accordance with CMR's Standard Terms & Conditions which are available on request and on CMR's website: www.cmr-med.co.za I/we confirm that I/we have read and understood the terms and conditions and agree to the terms thereof. All prices increase on the 1st of April each year.

    I/we hereby authorize Cape Medical Response to debit my/our account with the total monthly premium indicated above. I/we understand that a charge of R110 will be levied for any debit-order non-payment/s.


    Please note this form will only be sent if you have ticked the "I'm not a robot" box above AND clicked on the "submit" button below.
    Should you not hear from us within 24 working hours something is not right - please call Mark on 082 851 7645 or email mark@cmr-med.co.za