Membership Form

MM slash DD slash YYYY
Name
Physical Address (Where someone can sign receipt of your membership package)
Diabetic Type

Emergency Contact (To print on your membership card)

Please send me a free Blood glucose meter
I would like to receive info newsletters regularly
I would like to speak to a medxpert consultant about my medical aid benefits

Diabetes S.A. Membership

PLEASE NOTE: ANNUAL MEMBERSHIP FEES ARE DUE ONCE EVERY YEAR TO RETAIN MEMBERSHIP. YOUR MEMBERSHIP STARTS ON THE DAY YOU PAY, YOUR RENEWAL WILL BE DUE ON THE SAME DATE THE FOLLOWING YEAR. ALTERNATIVELY YOU CAN CHOOSE A MONTHLY DEBIT ORDER PAYMENT.
Price: R10.00
(scroll your donation amount)