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SA HIV Clinicians Society
Membership Portal

SA HIV Clinicians Society Online Membership Enrolment Form

In order to enrol as a member of the SA Clinicians Society, please fill in the form blow. At the end of the page there will be a "Submit" button which you should click once you have completed all the fields. You may get some validation errors which will appear at the top right of your screen when you click on submit, if you do please read the instructions on how to correct the input. Fields marked with a * are required fields.

Personal Details
Title: * Initials: *
First name: * Surname: *
Middle names:
Email Address: *
Telephone Work: Fax:
Telephone Mobile: * Telephone Home:
Date of birth: Ethnic Group:
Gender: Ethnic Group Other:
Postal Address (where you would like to receive post from the Society)
Building / Box / Address
Suburb:
Postal Code: Area Code:
Town: (other)
Province: (other)
Country: (other)
Profession
Select a profession:
Other:
Select a speciality:
Other:
Council Information (e.g. HPCSA/SANC)
Council number:
The physical address of the institution or organisation where you work

If you opt-in to the provider directory, this address will be available for health care users interested in HIV services

Name of organisation
Building Name
Address
Suburb:
Postal Code: Area Code:
Town: (other)
Province: (other)
Country: (other)
Primary Employment Affiliation
Primary Employment Affiliation:
Other:
Professional Activity
Primary Professional Activity:
Other:
Secondary Professional Activity:
Other:
Clinical HIV Qualifications

Doctors Only: Please indicate if you have passed a postgraduate diploma on the clinical management of HIV from one of the following institutions:

Date of completion
Membership Preferences

How would you prefer to receive your Southern African Journal of HIV Medicine?



Would you like to receive a posted copy of the Society’s magazine for nurses, HIV Nursing Matters? (note copies are available for free on the Society’s website: www.sahivsoc.org)


Would you like to participate in the Society’s online membership directory? (Note your contact information will be available to members only on the Society’s website)


Communication preferences
Check all that apply


Membership Portal

If you are a practicing health professional who sees HIV patients in the private sector and would like to be listed in our provider directory, which is accessible to the public via our website, please click the box below and complete the information.

Note!
Enter a unique password for this site, one that you do not use anywhere else.

Password:
Confirm password:  
Enrolment into provider network

If you are a practicing health professional who sees HIV patients in the private sector and would like to be listed in our provider directory, which is accessible to the public via our website, please complete the following information.


Practice web site:
Practice Email Address:
Practice Number:
Year began treating HIV patients:

Populations Served







Other:

Languages










Other:

Professional Associations



Other:

Medical insurance accepted:



Medical Aid Payment Policy


Medical Aid Remuneration Policy


By clicking on this button, I hereby certify that the information provided is to the best of my knowledge full and correct.

I accept full responsibility for any damages resulting directly or indirectly from the provision of incorrect information to the SA HIV Clinicians Society, and I acknowledge the right of the SA HIV Clinicians Society to remove from the service provider directory any information which is found to be incorrect or misleading.

Please click here for the full terms and conditions.

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