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Diabetes Education Society of South Africa

Membership Application

DESSA Membership Form
Annual Membership fee: R300-00

Title *

Name *

First

Last

ID NUMBER *

PHONE *

EMAIL *

PRACTICE ADDRESS *

POSTAL ADDRESS

PROFESSION *

PROFESSIONAL NUMBER *

SANC/HPCSA

PCNS/BHF NO. *

DIABETES COURSE ATTENDED AND YEAR *

HOURS OF WORK IN DIABETES PER WEEK *

YEARS OF DIABETES SERVICE *

GEOGRAPHICAL AREA OR SUBURBS COVERED

Please be specific to the area/s you serve

ARE YOU A SEMDSA MEMBER *

WOULD YOU LIKE YOUR CONTACT DETAILS MADE PUBLIC ON THE DESSA WEBSITE? *

I hereby consent to include my details are shared with Medical Aids/funders *

It is very important that you use your Name and Surname as reference when paying so that we can identify
your payment.

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