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TITLE ID NUMBER OR DATE OF BIRTH ADDRESS E-MAIL ADDRESS TELEPHONE (H) (W) (CELL) I authorise my medical practitioner to furnish and/or disclose to the Chronic Medicine Programme any fact relating to this application as well as any additional information that may be required from time to time. (Remember that your medical practitioner bears the responsibility of prescribing the medication for you, irrespective of the benefit authorised.) MEMBER S SIGNATURE DATE D D M M Y Y Y Y.

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How to fill out and sign Polmed chronic medicine management application form online?

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