Registration Form…
AFRICAN SKY HEALTH SERVICES:  CLIENT REGISTRATION FORM Fax to:
Yolandi Zammit Fax Number:
086 530 4931 OR e-mail
landi@afsky.co.za 
CLIENT details Company name (as you want it to appear on your Tax Invoice) 
Postal Address
Physical Address
Postal Code
Postal Code
  Telephone number VAT Registration number Company order number* Contact person (Operational)  Surname & name Occupation title e.g. Factory Manager  Telephone number Fax number E-mail Contact person (Accounts)  Surname & name Occupation title e.g. creditors clerk Telephone number Fax number E-mail Please tick : Customer accepts electronic invoices and statements 
Yes   
No  
Services required  Do you require any of the following medicals (if you are not sure what you need, let us know – we will assist)
Standard medical with audio at Jacobs office                Yes           Qty:                 Standard medical NO audiogram
Yes           Qty:                
Standard medicals on site (min of 10)*
Yes           Qty:                
Driver Medicals
Yes           Qty:                
Working At Heights Medical
Yes           Qty:                
Lead Medicals
Yes           Qty:                
Heat Stress Medical
Yes           Qty:                
Spirograms only (must have in house OHNP)                Yes           Qty:                 Audiograms only (available at Jacobs office only)         Yes           Qty:                
Other – please specify * for onsite medicals, please state area Payment due within in 30 days from date of invoice
Paypoint (debit & credit card) facilities available at our JACOBS office *Please note that African Sky Health Services do not require order numbers.  Clients will be invoiced irrespective of an order number received or not.  The responsibility to issue an order number is the responsibility of the client (it is not the responsibility of African Sky Health Services to get an order number)                
FOR CONVENIENCE, YOU CAN PRINT OFF AND COMPLETE YOUR CLIENT REGISTRATION FORM AND BRING IT INTO OUR OFFICE OR SEND IT TO US, PRIOR TO YOUR APPOINTMENT.
african occupational health