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info@medipet.co.za
(021) 701 2023

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Add a pet to your existing policy

Step 1 of 3 - You and Your Pet

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First Name*
Surname*
Email*

We will send your policy documents to this address
New Pet Name*
Date of Birth*
Date Format: DD slash MM slash YYYY

Pets younger than 6 weeks old cannot be added to your cover. We will request a complete vet history for all dogs between 8 & 9 years joining Option 1 & 2, and all cats 9 years & older joining Option 1 & 2. All dogs 9 years and older are offered our
Accident Cover only on joining.
Cat or Dog*
- Dog
- Cat
Breed of Dog*
Breed of Cat*
Gender*
- Male
- Female
Is your pet sterilised? (Optional)
- Yes
- No
Has your pet been adopted or rescued within the last 6 months?
- Yes
- No
Pets over the age of 6 months at the time of adoption, and without a complete vet record, are temporarily offered cover limited to R3 000 for the first 6 months after joining. This would not apply in the case of an accident during this period.
Policy No:*
This is your existing policy number for your current policy with MediPet.
Cover option for your pet*
- Option 1
- Option 2
- Accident Only
Option 1: Classic, day-to-day, affordable cover for illness, accidents & holistic wellness
Option 2: Ultimate, worry-free coverage for illness, accidents, dental, prescription foods & holistic wellness
Accident Only: Basic, unforeseen accident cover geared towards our golden oldies.
Cover option for your pet*
- Option 1
- Option 2
- Accident Only
Option 1: Classic, day-to-day, affordable cover for illness, accidents & holistic wellness
Option 2: Ultimate, worry-free coverage for illness, accidents, dental, prescription foods & holistic wellness
Accident Only: Basic, unforeseen accident cover geared towards our golden oldies.
Cover option for your pet*
- Accident Only
Accident Only: Basic, unforeseen accident cover geared towards our golden oldies.
Routine Care Add-On*
- Yes
- No
Routine Care Add-On contributes towards vaccinations, any tick/flea, deworming treatments, microchipping and sterilisation.

Has your pet ever been to the vet for medical reasons?*
- Yes
- No
We do not require routine care visit histories. These include vaccinations, sterilisations, deworming, tick & flea control, and microchipping.

Details of Visit

Approximate Date of Visit	Details of Visit to Vet	Has your pet fully recovered from this event?
			Edit Delete
There are no Entries.

Maximum number of entries reached.

Does your pet take any medication?*
- Yes
- No
Include any supplements and naturopathic/homeopathic substances.

Add information regarding Medication

Details of and reason for medication?	Has your pet fully recovered from the condition requiring medication?
		Edit Delete
There are no Entries.

Maximum number of entries reached.

Eye/Ear Conditions*
- Yes
- No

Add information regarding Eye/Ear Conditions

Date	Description of condition	Has your pet since fully recovered?
			Edit Delete
There are no Entries.

Maximum number of entries reached.

Lameness?*
- Yes
- No

Add information regarding Lameness

Date	Description of condition	Has your pet since fully recovered?
			Edit Delete
There are no Entries.

Maximum number of entries reached.

Vomiting/Diarrhoea?*
- Yes
- No

Add information regarding Vomiting/Diarrhoea

Date of visit?	Has your pet fully recovered?
		Edit Delete
There are no Entries.

Maximum number of entries reached.

Skin irritations or conditions?*
- Yes
- No

Add information regarding Skin Conditions

Date	Description of condition	Has your pet since fully recovered?
			Edit Delete
There are no Entries.

Maximum number of entries reached.

Any other diagnosed or treated conditions?*
- Yes
- No

Add information regarding any other diagnosed or treated conditions

Date	Description of condition	Has your pet since fully recovered?
			Edit Delete
There are no Entries.

Maximum number of entries reached.

Vet Contact

Vet Clinic or Hospital	Phone Number
		Edit Delete
There are no Entries.

Maximum number of entries reached.

Disclaimer*
- I accept that non-disclosure of any previous condition(s) may result in the cover being voided with immediate effect
- Please keep in touch with me. We won't send you anything unless we have something important to say.
Name
This field is for validation purposes and should be left unchanged.

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First Name*
Surname*
Email Address*

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Contact

info@medipet.co.za

Landline:	(021) 701 2023
Fax:	(021) 701 2027

Medipet Animal Health Insurance Brokers (PTY) Ltd (FSP Licence No: 32613)

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Approximate Date of Visit*
Date Format: YYYY slash MM slash DD
Details of Visit to Vet*
Has your pet fully recovered from this event?*
- Yes
- No

Details of and reason for medication?*
Has your pet fully recovered from the condition requiring medication?*
- Yes
- No

Date*
Date Format: MM slash DD slash YYYY
Description of condition*
Has your pet since fully recovered?*
- Yes
- No

Date*
Date Format: MM slash DD slash YYYY
Description of condition*
Has your pet since fully recovered?*
- Yes
- No

Date of visit?*
Date Format: MM slash DD slash YYYY
Has your pet fully recovered?*
- Yes
- No

Date*
Date Format: MM slash DD slash YYYY
Description of condition*
Has your pet since fully recovered?*
- Yes
- No

Date*
Date Format: MM slash DD slash YYYY
Description of condition*
Has your pet since fully recovered?*
- Yes
- No

Vet Clinic or Hospital*
Phone Number*