Registration – KMRS Portal

Name and Surname *

ID Number *

Mobile Number

Work Number

Website

Country of Permanent Residence

Email Address *

User Password *

Telephone Number

Practice Address

VAT Number (if applicable)

How long have you been practicing as a specialist?

HPCSA registration number

How long have you been practicing in total?

Qualification

Institution

Year

Has your memmbership with any Professional Body been refused/ suspended/ withdrawn or had special conditions imposed?

Yes
No

If YES, please provide details on the type of care and the number of patients treated in the past 12 months::

Which Professional organisations or associations are you currently a member of:

0

characters

Are you currently registered with HPSCA as a specialist?

Yes
No

Speciality

Sub-Speciality

Do you regularly treat patients who are citizens of other countries who have travelled specifically to receive treatment from you?

Yes
No

If YES, please specify:

Please confirm the % breakdown of the professional activities offered by you and for which you require cover:

2)

3)

Please enter the percentage of the professional activities offered by you and for which you require cover:

2)

3)

Should you perform any surgical procedures in an office-based setting (procedures performed under general, concious sedation, spinal or caudal anaesthesia) then please confirm what these procedures are below:

2) Should you perform any surgical procedures in an office-based setting (procedures performed under general, concious sedation, spinal or caudal anaesthesia) then please confirm what these procedures are below:

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