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. /