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Membership Application

Membership Application Form

Personal Details

Address(Required)
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Sex(Required)
Marital Status

Nostro Banking Details

Previous Membership

Have you been a member of any medical aid in the past?
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Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Package Applied For:

Select the package

Dependent Details

Surname, First Names, Date of Birth, Sex, Relationship

Medical History

Please carefully read and complete all required information. Failure to disclose material information or providing incorrect information can result in immediate cancellation of your membership or benefits.
(e.g., heart attack, angina, high blood pressure)
(e.g., varicose veins, blood disorders)
(e.g., jaundice, liver cirrhosis)
(e.g., asthma, tuberculosis)
(e.g., gastric ulcers)
(e.g., kidney stones)
(e.g., stroke, epilepsy)
(e.g., arthritis, back problems)
(e.g., diabetes, thyroid disease)
(e.g., schizophrenia, anxiety)
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Declaration

1. I declare that all information provided is accurate and complete. Failure to disclose any relevant information will render the membership null and void. 2. I understand that FA-MAS may request medical reports or examinations for further information. 3. I authorize FA-MAS to access my medical records, with the assurance that confidentiality will be maintained. 4. I agree to bear the costs associated with treatment for any conditions not declared in this form.
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