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Pendant code First name Date of birth Title D D M M Y Telephone no. Fax no. Y Y Y (H) (W) Cell E-mail address Preferred postal address Postal code SECTION 3: PATIENT CONSENT (TO BE SIGNED BY THE MEMBER OR GUARDIAN IF PATIENT IS A MINOR) 1. I hereby confirm that the information provided in this application is true and correct. 2. I acknowledge that Qualsa Healthcare (Pty) Ltd (Qualsa) is the administrator of the Programme and that any antiretroviral treatment prescribed as well.

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