Transcription of 11727 POLMED HIV forms Application Form …
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11727 POLMED HIV forms Application Form …
FaxDependent CodePostal Address for Confidential MailPostal CodeFirst NameConfidential EmailTelephone (Work)Telephone (Home)CellphoneFirst LanguageSecond LanguageSurnameHIV Application form ConfidentialTreatment Support is a vital part of the HIV programme. Contact details must be supplied to enable us to provide you with this DetailsDate of birthDDMMYYYYG enderPreferred form ofCommunicationMaleEmailFaxPostMedical SchemeMembership NameSurnameThe HIV programme does not dispense medication - Please fax this completed form to 0800 600 773 or email it to This SECTION needs to be completed by - THE APPLICANT | applications will be rejected unless signed by both Applicant and DoctorPrincipal (Main)
Clinical Stage 4 - Adult / Adolescent / Paediatric HIV wasting syndrome (See Clinical Guidelines for definitions) Pneumocystis pneumonia Recurrent severe bacterial pneumonia Chronic herpes simplex infection
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