Medical Professional Registration
1
BASIC INFORMATION
Title:
Prof.
Dr.
Mr.
Mrs.
Miss.
Ms.
First Name(s):
Surname:
Practice Name:
Email:
I would like email my listed?
Yes or No
Yes
No
Contact number:
(Work)
Contact number:
(Mobile - Optional)
I would like my contact number listed?
Yes or No
Yes
No
How would you like your contact number listed?
Work, Mobile or Both?
None
Work
Mobile
Both
2
GEOGRAPHICAL INFORMATION
How would you like your practice listed?
(Please click to select and fill in the information below the buttons)
List by Geographical information only
List by Full Address
DETAILS FOR LISTING
Province:
Eastern Province
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
Northern Cape
Western Cape
Other
DETAILS FOR OFFICE USE ONLY
Street Name:
Suburb:
City:
Postal Code:
Confirm Listing:
Full Address
Geographical
3
QUALIFICATIONS / PRIVATE OR STATE HEALTH
MP number:
Degree:
Speciality:
Dermatologist
Dietician
ENT Specialist
Family Medicine
General Practitioner
Immunologist
Internal Medicine
Laboratory Immunologist
Paediatrician
Physician
Pulmonologist
Other
Diploma in Allergy
Yes or No
Yes
No
Registered allergist?
Yes or No
Yes
No
Other Qualifications:
Private health?
Yes or No
Yes
No
State health?
Yes or No
Yes
No
Areas of Expertise:
None
General allergy
Occupational allergy
Alpha-Gal
Asthma
Anaphylaxis
Drug allergy
Drug challenge
Drug desensitisation
Eczema
Food allergy
Food challenge
Hereditary Angioedema
Immunotherapy
Primary immune deficiency
Rhinitis
Skin testing
Spirometry
Urticaria
Register