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 Not In A Job Presently, Have You Been Boarded? *

Email Address: *

Cell Number: *

Marital Status: *

Name And Contact Number Of Spouse / Partner / Next Of Kin And Your Relationship To Them: *

Country Of Birth: *

Full Residential Address Including Town And Province: *

Postal Code: *

Race: *

Gender: *

Age: *

ID Number: *

Date Of Birth: *

Do You Have Children And What Age Are They? *

Do You Belong To A Medical Aid? *

Are You A State Patient At A Government Hospital? *

If So, Which Hospital? *

Current Neurologist: *

Who Referred You To Your Current Neurologist: *

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? *

Please Write Down, Your MS Story / Journey / History From Then To Now: *

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

Where Did You Hear About Us? *

Name

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