Thank you for your purchase!

We have received your payment and will process your order. Please ensure to submit and update your details below.

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.

    Patient Particulars

    Disc Number (to be allocated)

    Contact Details

    Medical Aid/Hospital Plan

    Emergency Contact 1

    Emergency Contact 2

    Medical Details

    Medical Condition(s)

    Medicines

    Allergies

    Disclaimer

    BY MY ACCEPTANCE OF THIS DOCUMENT, I SPECIFICALLY INDEMNIFY AND HOLD HARMLESS THE MANUFACTURER AND OR ANY OTHER PARTIES OR PERSONS ACTING ON THEIR BEHALF, FROM AND AGAINST ALL CLAIMS, LIABILITIES OR EXPENSES ARISING FROM ANY ACTION OR PROCEEDINGS AND WILL NOT HOLD THEM RESPONSIBLE FOR ANY MATTER ARISING FROM THEIR SELLING OR ISSUING OF MY EMBLEM, ANY NEGLIGENCE ON MY PART AND ANY CONSEQUENCE ARISING FROM INACCURATE INFORMATION BEING PROVIDED BY MYSELF, ACKNOWLEDGE THAT IT IS MY DUTY TO UPDATE AND ENSURE MY INFORMATION IS CURRENT AND CORRECT. I AUTHORISE ELIXIR MEDICAL SHIELDS OR ASSOCIATED PARTIES OR PERSONS TO DISCLOSE ANY AND ALL INFORMATION ON THIS APPLICATION FORM TO ANY PERSONS IN RESPONSE TO ANY EMERGENCY CALL. BY MY ACCEPTANCE I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THIS DISCLAIMER AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS THEREOF.

    Banking Details

    Annual Subscription

    The ANNUAL SUBSCRIPTION is payable ONLY from the SECOND YEAR of ownership. There is no charge for the first year. Please complete the authorisation below as this obviates the need for us to send accounts. If you do not operate a bank account please call us at 0861 115 178 to make alternate arrangements and enable us to activate your bracelet.

    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

    R 100 RAND --- (2020)

    Being payment of my annual subscription only commencing 1 year AFTER the date of purchasing a bracelet 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. If this debit order is dishonoured for any reason, ELIXIR is authorised to resubmit it for payment until such time as it is honoured.