Database of Pulmonary Hypertension in South Africa

Registration

Please note that we only support the following countries: South Africa, Botswana, Lesotho, Madagascar, Mauritius, Mozambique, Namibia, Swaziland and Zimbabwe. Please email PHA@PHAssociation.org to get in touch with your closest supporting association.

Since a consolidated database for Pulmonary Hypertension does not currently exist in South Africa, we would appreciate it if Patients, Caregivers and Medical Professionals would be so kind as to REGISTER for FREE so that we can create a database of all current patients. In doing so, we will have strength in numbers, so that we can work together as a community for the benefit of all those affected by Pulmonary Hypertension.

To register, please complete the form.

Caregiver/Family Member

1. Caregiver information

I hereby consent that PHASA can use my information for the purposes of building a PHASA national database and only that purpose.

ID*^?

Name*

Surname*

Email*

Contact Number*

Relationship to Patient*

Physical Address

Street Address

Street Address Line 2

City

Province

Postal/Zip Code

Country

Patient Information

ID*^?

Name

Surname

Contact Number

What is the diagnosis of the patients you are caring for?*

3. Get Involved

Would you like to get involved with our activities?

Would you like to serve on a sub-commitee for us?

Would you like to volunteer at our events?

Send me a free MySchool card to support more PH patients in South Africa

Healthcare Professional

1. Healthcare Professional information

I hereby consent that PHASA can use my information for the purposes of building a PHASA national database and only that purpose.

Practice Number*

Name*

Surname*

Email*

Contact Number

Hospital

Speciality

Other Speciality

Diseases/ Areas of interest

Physical Address

Street Address

Street Address Line 2

City

Province

Postal/Zip Code

Country

2. Get Involved

Would you like to get involved with our activities?

Send me a free MySchool card to support more PH patients in South Africa

Stakeholder / Interested member of the public

1. Stakeholder information

I hereby consent that PHASA can use my information for the purposes of building a PHASA national database and only that purpose.

ID*^?

Name*

Surname*

Email*

Contact Number

What is the reason for your interest in Pulmonary Hypertension, or your connection to the condition?

Physical Address

Street Address

Street Address Line 2

City

Province

Postal/Zip Code

Country

2. Get Involved

Would you like to get involved with our activities?

Would you like to serve on a sub-commitee for us?

Would you like to volunteer at our events?

Send me a free MySchool card to support more PH patients in South Africa

Database of Pulmonary Hypertension in South Africa

Registration

Patient Registration Form

1. Patient information

Physical Address

2. Mandatory Beneficiary Reporting

How did you hear about us?

What are your reasons for registering with us?

3. Patient's Medical Information

Symptoms

Is the patient treated by any of the below specialists?

Does the patient receive any of the below auxilliary services?*

4. Guardian/Parent's details

5. Get Involved

Caregiver/Family Member

1. Caregiver information

Physical Address

2. Patient Information

Patient Information

3. Get Involved

Healthcare Professional

1. Healthcare Professional information

Physical Address

2. Get Involved

Stakeholder / Interested member of the public

1. Stakeholder information

Physical Address

2. Get Involved