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Thalassaemia Society of University Hospital
Address: Department of Paediatrics
University Hospital
Lembah Pantai
59100 Kuala Lumpur
Malaysia.
Telephone: 03 - 7502275
Fax : 03 -7556114

Membership Application Form

Name:
Male Female Age:
Address1:
Address2:
Telephone: e-mail:
Type of Membership:
Ordinary (>18yrs)
Non-voting (<18yrs)
Life
Entrance Fee: RM10.00
Annual Subscription Fee: RM10.00 p.a.
Life Membership: RM100.00
Total: RM
 
I would like to help in the running of THASUH activities.
I am
the of patient named
UHRN: currently on treatment for thalassaemia at University Hospital.
 
Enclosed no:
of RM for membership application.