Application form for third-line antiretroviral therapy - updated 13 Oct 2017
National Department of Health
Please find attached the application form that is required to be completed for access to Third Line Antiretroviral Therapy. Please complete the form using the following steps:
• Download: Please download the PDF document.
• Open: Open the PDF document using Adobe Reader. Ensure you have the latest version of the form may not work properly.
• Fill: This is an editable PDF, and the minimum required fields will be highlighted. Please click on each field and enter the required patient information.
Please do not print out the document to complete by hand.
• Save: Once you have completed the document please save it to your computer by clicking the icon on the top left of the screen. Save it using the patient name and surname as a unique identifier.
• Submit: Close Adobe and attach the completed and renamed application form to an email and submit it to the following email address: TLART@health.gov.za