MAY MEASUREMENT MONTH (MMM) SCREENING PERMISSION REQUEST
CONSENT: I am of legal age (18 years or older). I understand the purpose for disclosing this personal information. Collection of this information complies with The Protection of Personal Information Act 4 of 2013 (POPI), South Africa. If you have any questions about the Privacy Policy contact info@hypertension.org.za
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Yes
No
Please note: Consent is needed to complete this form.
Date of Request
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Day
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Month
Year
Date
Person Requesting Permission
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Title
First Name
Last Name
Position / Role in participating entity
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Name of participating entity
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Company / Hospital Group / Pharmacy Group / Practice Name / Organisation / University or type N/A if not applicable
Street Address
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Site Location (Please indicate the city/town or suburb. e.g. Bisho, Cape Town, George, Polokwane, Qonce, Soweto etc)
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Province
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Please Select
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Upload a full list of participating entities if more than one
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Company / Hospital Group / Pharmacy Group / Practice Name / Organisation / University
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Upload company logo
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Browse Files
Size: Maximum 10MB File types allowed: jpeg / jpg / png
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Upload Company Email Signature
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Browse Files
Size: Maximum 10MB File types allowed: jpeg / jpg / png
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Confirmation of Information
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I Confirm: I completed the permission request in my professional capacity. All provided information is true and correct.
Signature
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Submit
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