| Signature |  |
|---|---|
| Are you a medical aid member? | Yes |
| Medical Scheme Name | Bonitas |
| Medical Scheme Plan | Standard |
| Medical Aid Number | 02025358962 |
| Allergies | None |
| Next of Kin Phone Number | 0711089009 |
| Next of Kin Name & Surname | Dimakatso Tsieane |
| Photo of your ID/Passport Document |  |
| Head & Shoulders Photo |  |