SA Membership Application

SA Membership Form

Annual Membership Fee: R300 per annum or R50 per month via EFT

Ref: Your name and surname
Send proof of payment to info@multiplesclerosis.co.za
Bank Details
MSSA
Standard Bank – 073084697
Branch Code – 050410

Title: *

Name: *

Surname: *

Current Occupation: *

If you are boarded, what was your previous occupation: *

Email Address: *

Cell Number: *

Marital Status: *

Who is your Next of Kin: *

What is your relationship to your Next of Kin: *

Telephone number of Next of Kin: *

Country Of Birth: *

Full Residential Address Including Town And Province: *

Postal Code: *

Race: *

Gender: *

Age: *

ID Number: *

Date Of Birth: *

How many children do you have? *

How old are they? *

Do You Belong To A Medical Aid? *

If yes, which Medical Aid do you belong to? *

Are You A State Patient At A Government Hospital? *

If So, Which Hospital? *

Current Neurologist: *

Telephone number of your neurologist: *

Physical address of your neurologist *

Email address of your neurologist: *

Who is your General Practitioner (GP) / Primary Doctor: *

Telephone number of your GP / Primary Doctor: *

Physical address of your GP / Primary Doctor: *

Email address of your GP / Primary Doctor: *

Take your time and write down a complete history recording of your MS journey: *

Name Your First MS Symptoms: *

Date Of First Symptoms: *

Date Of Positive Diagnosis: *

Type Of MS: *

Current MS Treatment: *

Name Your Current Treatment If Not Found On The List In The Previous Question: *

Do You Have An MS Support Nurse In Your Area? *

Any Family History Of MS? *

Are You Keen To Join An MS Support Group On Whatsapp? *

Are You Keen To Join An MS Support Group On Facebook? *

Would You Like To Add Anything Else Before You Submit? *

Where Did You Hear About Us? *

End note: Please note that by clicking submit, you acknowledge that you are sharing confidential information with MSSA and accept MSSA’s privacy policy and disclaimer. *

Privacy Policy: Multiple Sclerosis South Africa (MSSA) respects your privacy and is committed to protect the personal information that you share with us. Our database contains private information including name, address, contact information and medical information. If you provide any private or non-public information it will be restricted to site administrators and individuals on a need-to-know basis and will not be sold or given outside of MSSA without consent from you. *

Disclaimer: MSSA is a resource for sharing information and support. MSSA members, employees and executive board members do not offer medical advice. The information provided on the MSSA website, newsletter and message board are designed to support, not replace, the relationship that exists between a patient/MSSA member and his/her physician. Please verify any information you receive from MSSA with other sources and with your licensed health care provider. Decisions regarding medical care should be made with your healthcare provider. Consumers should never disregard or delay seeking medical advice due to the content of this website. The MSSA executive and medical boards, volunteers and moderators do not assume, and hereby disclaims, any and all liability to any person or entity for any claims, damages, liability, or other loss including, without limitation, any liability for injury or other damage resulting from any use of, or reliance on, this service or from the posting of any content or material by any third party. *

Phone

Send proof of payment of your registration to info@multiplesclerosis.co.za

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