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Application Form Confidential - Aid for AIDS

first NameSurnameMedical SchemeGenderMembership / PlanPatient DetailsFirst NameSurnameDependant CodeGenderID NumberDate of BirthTreatment Support is a vital part of the AfA programme. Contact details must be supplied to enable us to provide you with this EmailPreferred form of communicationFAXP ostal Address for Confidential mailCellphonePostal CodeEMAILPOSTP rincipal (Main) Member DetailsYYYYDDMMT elephone(Work)Telephone(Home)MALEFEMALEM ALEFEMALEF irst LanguageWhat time of day is the best time for AfA to contact you?MORNINGAFTERNOONS econd LanguageFirst NameTelephone(Home)Telephone(Work)Cellph oneSurnameNext of kin or buddy who can be contacted if we cannot reach you (should know your HIV status)I understand that all personal clinical information supplied to the Aid for AIDS (AfA) programme will be used to determine access to specific benefits for people with HIV infection.

Doctor Details Clinical History Type of screening test When was HIV infection first diagnosed? (Please attach reports) Is the patient currently being treated for tuberculosis?

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HIV/AIDS

www.aidforaids.co.za

into new relationships can be considered. • A lot can be done to help you lead a healthy, normal life and slow down the time to developing AIDS if HIV is found early (before getting sick) in your blood. • If you are HIV positive and register with Aid for AIDS, approval can be provided for multivitamins and preventative

  Relationship, Positive

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