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) Member DetailsGenderMaleFemaleFemaleSurnameCell phoneFirst NameTelephone (Work)Telephone (Home)Next of kin or trusted friend who can be contacted if we cannot reach you (should know your HIV status)
HIV Application Form Confidential Medical Aid Number Dep Code Patient Name Page 2 of 4 v2.0.1 This SECTION needs to be completed by - THE DOCTOR
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