Membership application form

If you are a patient at either the Kobler clinic, 56 Dean Street Clinic or the Nkosi Johnson Unit. You are welcome to join the patient forum and our private email list. If you would like to join please fill in your details below.

You do not have to give your family name if you do not want to. It will not affect you application.
You will have to have a valid email address as all corrispondance for the group is done by email. If you do not have an email account please contact us as we can help you get an account.
Please enter the number/ text you see in the image in the box below - this is for testing whether you are a human visitor and to prevent automated spam submissions