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D provider telephone: 0860 00 4367 Only complete this form if you are a fully registered member of GEMS Section A: To be completed by the member (please print using block letters) Please book at least 30 minutes with your doctor in order for him/her to examine you and complete this form. The ideal person to do this is the registered doctor who regularly prescribes your medicine. Please keep a copy of the completed form for your records. Member/patient signature is essential to process this app.

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