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Gems Chronic Forms
Plan by fax 0861 004 367 or email
enquiries@gems.gov.za.
Attach all relevant special investigations and lab results to
this form when submitting.
Submit form via fax 0861 004 367 or email; enquiries@
gems.gov.za.
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Please tick appropriate box and fill in relevant sections
Section A: Membership Details
Patient Details
Surname _______________________________________________ First name ___________________________________________
Option/Plan: _________________________
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