| Signature |  |
|---|---|
| Are you a medical aid member? | Yes |
| Medical Scheme Name | Des-chem medical insurance |
| Medical Scheme Plan | Core and accident cover |
| Medical Aid Number | KH161254 |
| Allergies | N/A |
| Next of Kin Phone Number | 0795964635 |
| Next of Kin Name & Surname | Kazia Plaatjies |
| Photo of your ID/Passport Document | ID-1-1.pdf |
| Head & Shoulders Photo |  |