IMASA Membership Signup

IMASA Membership Form

Name

First Last

Email(Required)

Phone

Profession/Speciality

Registered Council/HPCSA No.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth

Gender

Phone

Home Number

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Number

City

Are you willing to volunteer your time towards IMA activity?

Will you be prepared to write articles of interest for circulation?

I do hereby give my consent, to IMASA, to process My contact details including my email address, cell number, work number, physical and postal address, HPCSA No etc, to receive relevant information in relation to CPD accredited programmes and other events / project information at IMASA Adding me to regional and national whatsapp groups Providing my details to sponsors and other third parties who may on occassion require my information Providing my details to sponsors and other third parties who may on occassion require my services etc in accordance with the provisions of the Protection of Personal Information Act.

Which branches/committees would you like to join?

Doctors and Dentists

Price: R1,450.00

(Please select 1)

Allied health professionals, Pharmacists and Medical Interns

Price: R900.00

(Please select 1)

Nurses, Paramedics, Acquaintances

Price: R300.00

(Please select 1)

Medical Students

Price: R0.00

(Please select 1)

IMASA Membership Signup

IMASA Membership Form

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