CHRONIC MEDICATION APPLICATION
SECTION A: TO BE COMPLETED BY APPLICANT/INJURED
APPLICANT DETAILS
Surname:
Initials:
Date of birth:
Gender:
Occupation:
RMA Claim No:
Industry No:
Date of Accident:
/
/
Physical Address:
City:
Code:
Postal Address:
Code:
Nearest Post Office:
Code:
Delivery Method: (please indicate preference)
Tel (H):
Post
Door to door
Tel (W):
CELL:
MEDICAL HISTORY
Please indicate whether you suffer from a chronic condition as well as the treatment received for that condition:
Chronic condition/disease
Date diagnosed
Treatment
Use of medicine not prescribed by a medical doctor (over the counter medication i.e. pain killers, muscle relaxants etc.)
1.
2.
3.
DECLARATION
I declare that the information contained herein is correct. I understand that RMA needs to access my personal clinical information
to make an informed recommendation regarding my chronic medication needs.
Signature:
Date:
/
/
SECTION B: TO BE COMPLETED BY THE HEALTHCARE PROVIDER
CLINICAL DETAILS
Height:
Urine:
cm
Weight:
Allergies:
kg
Blood pressure:
HIV status:
/
mmHg
Injury and description of disability:
CHRONIC MEDICINE PRESCRIBED FOR CONDITION
Injury related problem
ICD10
Medication prescribed
Dosage
OTHER PRE-EXISTING CONDITIONS
Chronic condition/disease
ICD10
Medication prescribed
Dosage
PRESCRIBING DOCTOR DETAILS
Surname:
Initials:
Practice No:
Email:
Tel:
Cell:
Address:
Code:
Signature:
Date:
/
Please submit a prescription together with the completed chronic application form to an RMA case auditor.
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