| Signature |  |
|---|---|
| Are you a medical aid member? | Yes |
| Medical Scheme Name | Gems |
| Medical Scheme Plan | Emerald |
| Medical Aid Number | 001115983 |
| Allergies | None |
| Next of Kin Phone Number | 0670537014 |
| Next of Kin Name & Surname | Lebogang jeaneth Nyatlo |
| Photo of your ID/Passport Document | Tiisestso-ID.pdf |
| Head & Shoulders Photo |  |