Please complete this online form or download the PDF version for completion at your pharmacy.
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PATIENT ASSIST APPLICATION FORM

Patient Assist Card Number:
Applicant's Full Name:
RSA ID Number:
Date of Birth:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
Gender:	M F
Residential Address:
Postal Address:
CONTACT DETAILS
Home telephone:
Cell number:
Email address:
Doctor's name:
Practice number:
Contact number:
Pharmacy name:
Contact number:
PERSONAL DETAILS
Medication:
Please give details of medication required(*):
Condition being treated (optional) (*)
(*)Pharma Dynamics would like to send support material to you that may assist in the management of your disease. New medication from Pharma Dynamics will be coming onto the South African market from time to time, and we may be able to support you with other health conditions that you may have. Please discuss your medicinal needs with your pharmacist and doctor who will be able to guide you in accessing this cost-saving programme.
Agreement: Participation in the Pharma Dynamics Patient Assist programme is subject to terms and conditions as adopted and varied by Pharma Dynamics from time to time. The terms and conditions are available on request and include (without limitation) the following: The applicant agrees to allow Pharma Dynamics and its appointed agent access to the personal information in this document. It should be noted however that no individual named information will be used outside of this programme or supplied to anyone other than your named doctor and pharmacist. Pharma Dynamics makes no warranty as to the use of its medication other than the claims made in the individual package insert.
I confirm that I am not a member of a Medical Aid or receive any other subsidy for medicines.
Date: DD/MM/YYYY