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Registration Form

Registration Form for New Members



Personal details of applicant

Title
First Names *
Surname *
Address
Town
Code
Tel *
Fax
E- mail *
cell phone *
MP number *
I am connected to the following hospital/s
   

I am applying for

FULL membership (Cardiologists, Surgeons, Paediatricians, Physicians)
ASSOCIATE membership (all other allied professionals)
   
- And membership of the following REGIONAL BRANCH
   
 
   
I am a member of the following Special Interest Group(s) of SA Heart

CASSA (Arrhythmia)
SASCAR (Research)
PCSSA (Paediatric)
CISSA (Imaging)
Surgical Interest Group
SASCI (Interventional)
LASSA
HeFSSA (Heart failure)

My specialty/qualification is

Cardiologist
Physician
Cardiac Surgeon
Paediatrician
Nursing staff
General Practitioner
Technologist
Radiographer
Research
Industry

My special interest is: (e.g. valve disease, coronary intervention or other)


 
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