If Yes, please attach a certificate of membership from your previous medical aid society. FA-MAS reserves the right to waive or impose waiting periods against a certificate of membership.

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.

Details of Conditions (if applicable): If you have ticked "Yes" to any of the above, please provide details (condition, date, treatment, medication) . Attach a separate sheet if needed.

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.