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    MAIN MEMBER INFORMATION

    ID NUMBER *
    SURNAME *
    FULL NAMES *
    INITIALS
    GENDER
    TITLE
    DATE OF BIRTH *
    CELL NUMBER *
    HOME NUMBER
    WORK NUMBER
    EMAIL ADDRESS *
    EMAIL STATEMENT?
    POSTAL ADDRESS *
    POSTAL CODE *
    PHYSICAL ADDRESS
    POSTAL CODE
    MEDICAL SCHEME
    PLAN/OPTION
    GAP COVER?
    MEMBER NO
    MAIN MEMBER DEP CODE

    PATIENT INFORMATION

    ID NUMBER *
    SURNAME *
    FULL NAMES *
    NICK NAME
    INITIALS
    GENDER
    TITLE
    DATE OF BIRTH *
    CELL NUMBER *
    Use this number for appointments / test results?

    Main member's Cell Phone number will be used if the above is No
    HOME NUMBER
    WORK NUMBER
    EMAIL ADDRESS
    OCCUPATION
    MARITAL STATUS
    RELATIONSHIP TO MAIN MEMBER
    PATIENT DEPENDANT CODE
    AGE
    HEIGHT
    WEIGHT
    REFERRING DR
    TEL. NO
    GP
    TEL. NO

    NEXT OF KIN

    Not from the same physical address

    INITIALS
    TITLE
    SURNAME
    FULL NAMES
    CELL NUMBER
    RELATIONSHIP TO PATIENT