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Axial Spondyloarthritis South Africa (ASSA) Intake Form
Hello all your AS Warriors! This form will add you to our growing database of fellow AS community members. Its purpose is to allow us to better understand the challenges of AS in South Africa and make YOUR voices heard. 

By completing this form, you give us permission to collect your data which will be protected by the POPI Act.

Yours in health, wellbeing and community collaboration,

Lauren and Maranda  
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Email *
What is your Full Name? *
What is your Surname? *
What is your date of birth? *
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What is your email address? *
What is your contact number? *
When were you first diagnosed with Ankylosing spondylitis?  
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When did you start having symptoms associated with AS?
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Which South African Province do you reside?
Please give us the details of your rheumatologist? (Name, contact number, email )
What are you looking for in an AS support group?
Would you like to be a volunteer for ASSA? *
Required
If you answered YES to become a volunteer, could you indicate skill set available ?
I'd like to be included in AxspA mailing lists, and receive information that we think is important to you and your AxspA. No spam! *
Is there anything else you'd like the Axial Spondyloarthritis International Federation to know about your experiences with this condition?
Are you HLA-B27 Positive
Clear selection
Demographics/Ethnicity/Population Group
How are you medically funded
Clear selection
Thank you!
A copy of your responses will be emailed to the address you provided.
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