This captures your basic details in the form of:

  • Name / Practice Name
  • Physical and Postal Addresses
  • Phone, Fax and Mobile Numbers
  • Email and Website Information


A normal listing entitles you to be placed in up to 5 medical disciplines.

A premium listing allows you to capture all the information of a normal listing and in addition add more information about your practice, including any graphics / logo that you may have.

In addition to a Premium Listing, we are offering Medical Practitioners that have taken up an annual listing in Medicalis a discounted, custom designed website for their practice. The website will include the following features:

  • A full custom developed content management website, enabling owner updating
  • A free domain registration and renewal
  • Five free email addresses at your domain, e.g.


This will enable you to post articles, publish papers and research online in your own website.

Dentist's Information

Dentist's Name*

Medical Centre / Hospital / Building Name

Suite No.

Practice No.


Physical Address



Postal Code

Town / City*


Postal Address



Postal Code

Town / City


Contact Info




Publish Mobile on Internet?


Publish Email on Internet?


Dental Disciplines

Dental Practitioner
Oral Hygienist
Dental Therapist
Maxillo Facial / Oral Surgeon

Description of Practice

Listing Options

Choose one of the following listing options:*

Normal Listing

Premium Listing

Premium Listing Plus Website

Debit Order Information

Only complete if you selected the debit order option for payment

Account Name:

Account Number:

Bank Name:

Branch Name:

Branch Code:

Account Type:

Terms and Conditions for Debit Order

I hereby request and authorize you to draw against my account with the abovementioned bank (or any other bank or branch to which I may transfer my account) the sum as indicated / ticked above, or any variable amount pertaining to this agreement. This being the amount necessary for the settlement of a listing subscription on the Medicalis On-line database.


All such withdrawals from my account by you shall be treated as though they had been signed by me personally. I the undersigned, "instruct" and authorize your agent, Netcash (Pty) Ltd, to draw against my account. I understand that if bank details have been supplied the withdrawals authorized here will be processed by BankServ.


I agree to pay any banking charges relating to this debit order instruction. This authority may be cancelled by means of giving you thirty days notice in writing, sent by post or email, but I understand that I shall not be entitled to any refund of amounts, which you have withdrawn whilst this authority was in force if such amounts were legally owing to you.


Assignment: I acknowledge that the party hereby authorized to effect the drawing(s) against my account may not cede or assign any of its rights and that I may not delegate any of my obligations in terms of this contract/authority to any third party without prior written consent of the authorized party.


Verification Image:

Please enter the alphanumeric characters as you see them above. The verification image is cAse SeNsitIvE.

By selecting "Yes" alongside, I hereby agree to including my name in Medicalis and to settle all due listing fees.*

All fields marked with a (*) are compulsory.