ENROLLEE REGISTRATION FORM

BASIC INFORMATION

PLAN TYPE

EMPLOYEE/DEPENDANTS INFORMATION (ONLY DEPENDANT UNDER 21 YEARS ARE ELIGIBLE)

COMPANY INFORMATION

MEDICAL HISTORY/HEALTH DECLARATION

  • 1
  • Step 2
  • Step 3
  • Step 4
  • Step 5

Choice of Healthcare Provider (Hospital)

Input Healthcare Provider (Hospital)

General Information

Principal Photograph

Max. size: 128.0 MB

Enrollee Registration No.

Name of Principal Enrollee (surname, First name, others).

Residential address

State

E-mail

Phone No.

Date of Registration

Personal Information

Date of Birth

Sex

Marital Status

State of Origin

Nationality

Plan Type

Tick the appropriate plan type

Employee

Surname

First name

Middle name

Date of Birth

Sex

Genotype

Blood Group

Hospital Chosen

Spouse

Surname

First name

Middle name

Date of Birth

Sex

Genotype

Blood Group

Hospital Chosen

Spouse Photograph

Max. size: 128.0 MB

Dependent Child 1

Surname

First name

Middle name

Date of Birth

Sex

Genotype

Blood Group

Hospital Chosen

Dependent Child 1 Photograph

Max. size: 128.0 MB

Company Information

Name of Company

Branch

Department

Employer’s Authorized Signature

Max. size: 128.0 MB

Have you or anyone mentioned in this form been diagnosed with any of these medical conditions below?

Please tick as appropriate

If any is ticked, kindly give details here:

Precious HMO Fitness Club

Indoor

Outdoor

MEMBERSHIP DECLARATION

1. I certify that all information provided in this form are true to the best of my knowledge.
2. I declare that any false information given by me in the above questionnaire or the non-disclosure of a fact if identified later will render the membership null and void.
3. I agree to abide by the terms and conditions governing membership and access to the health benefits covered by the plan in which I have enrolled.
4. I hereby give my permission to care givers to release any information requested by Precious Healthcare LTD with respect to any claim or delivery of medical services on my account or that of my dependents for the sake of quality control, statistical and legal analysis,.

ENROLLEE REGISTRATION FORM

BASIC INFORMATION

PLAN TYPE

EMPLOYEE/DEPENDANTS INFORMATION (ONLY DEPENDANT UNDER 21 YEARS ARE ELIGIBLE)

COMPANY INFORMATION

MEDICAL HISTORY/HEALTH DECLARATION

  • 1
  • Step 2
  • Step 3
  • Step 4
  • Step 5

Choice of Healthcare Provider (Hospital)

Input Healthcare Provider (Hospital)

General Information

Principal Photograph

Max. size: 128.0 MB

Enrollee Registration No.

Name of Principal Enrollee (surname, First name, others).

Residential address

State

E-mail

Phone No.

Date of Registration

Personal Information

Date of Birth

Sex

Marital Status

State of Origin

Nationality

Plan Type

Tick the appropriate plan type

Employee

Surname

First name

Middle name

Date of Birth

Sex

Genotype

Blood Group

Hospital Chosen

Spouse

Surname

First name

Middle name

Date of Birth

Sex

Genotype

Blood Group

Hospital Chosen

Spouse Photograph

Max. size: 128.0 MB

Dependent Child 1

Surname

First name

Middle name

Date of Birth

Sex

Genotype

Blood Group

Hospital Chosen

Dependent Child 1 Photograph

Max. size: 128.0 MB

Company Information

Name of Company

Branch

Department

Employer’s Authorized Signature

Max. size: 128.0 MB

Have you or anyone mentioned in this form been diagnosed with any of these medical conditions below?

Please tick as appropriate

If any is ticked, kindly give details here:

Precious HMO Fitness Club

Indoor

Outdoor

MEMBERSHIP DECLARATION

1. I certify that all information provided in this form are true to the best of my knowledge.
2. I declare that any false information given by me in the above questionnaire or the non-disclosure of a fact if identified later will render the membership null and void.
3. I agree to abide by the terms and conditions governing membership and access to the health benefits covered by the plan in which I have enrolled.
4. I hereby give my permission to care givers to release any information requested by Precious Healthcare LTD with respect to any claim or delivery of medical services on my account or that of my dependents for the sake of quality control, statistical and legal analysis,.