IMA Membership Application

Consider your annual membership fee a small donation towards the projects and upliftment of communities in need.

Name*
Surname*
Date of Birth
Date Format: MM slash DD slash YYYY
Residential Address
Postal Address
Practice Address
Tel (Work)
Tel (Home)
Cell*
Email*
Whatsapp Number
Facebook Page
Twitter
Instagram
Website
Profession / Speciality
Registered Council Number
HPCSA Number
Select your current Profession:
Please Note: Rates are subject to increase every year.
Select
- Doctor, Dentist, Pharmacist
- Allied Health Professionals: Physios, OTs, Podiatrists, Psychologists
- Intern
- Nurse
- Medical Student - Free
Total Due Per Annum:
R0.00

Select your current Profession: