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Online Registration
Please complete the form below and press send mail at bottom of page.

Please ensure all details supplied are correct. Elixir Shields or associated parties or persons cannot be held responsible for any ommisions and or mistakes supplied on this form. The data below will be captured exactly as supplied to us on this form.

Disc Number:
Mr Mrs Miss
Surname:
Full Name:
Email Address
Home Address
Postal Address
Date of Birth
ID Number

Contact Details:

Phone (Home)
Phone (Work)
Cell
E-Mail

Medical Aid / Hospital Plan

Fund Name
Membership Number

Emergency Contacts

Primary Contact
Mr Mrs Miss
Phone (Home)
Phone (Work)
Cell
E-Mail

Second Contact
Mr Mrs Miss
Phone (Home)
Phone (Work)
Cell
E-Mail

Medical Details

Doctors Name
Contact Numbers
Surgery
Emergency
Cell
Blood Group (If Known)
Medical Condition
Medicines - Name and Dosage
Allergies - Please List
Todays Date

ANNUAL SUBSCRIPTION

The MONTHLY/ANNUAL SUBSCRIPTION is payable ONLY from the SECOND YEAR of ownership. There is no charge for the first year. I, Hereby authorise ELIXIR to draw against my/our account with the under mentioned bank (or any other bank or branch to which I/we may transfer my/our account) the sum of Standard Package R 60.00 (sixty rand) per year Standard Package Documax Package R 15.00 (fifteen rand) per month Documax Package . BEING PAYMENT OF MY Monthly ANNUAL SUBSCRIPTION ONLY COMMENCING IN MONTH. The month in which you bought your bracelet) YEAR: (Next year) and continuing until termination by me/us by giving you thirty days’ notice in writing. In the event of an increase in this amount in excess of 10% per annum, I must be advised by ELIXIR, prior to such withdrawal. All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally.

Due to Internet security reasons and bank detail theft on the internet Elixir will not require you to supply your banking details on this form. Elixir will contact you for your banking details telephonically on receipt of this application form.

Debit Order authorization
Send me a carbon copy of this email.