ENROLLEE REGISTRATION FORM
BASIC INFORMATION
PLAN TYPE
EMPLOYEE/DEPENDANTS INFORMATION (ONLY DEPENDANT UNDER 21 YEARS ARE ELIGIBLE)
COMPANY INFORMATION
MEDICAL HISTORY/HEALTH DECLARATION
Choice of Healthcare Provider (Hospital)
Input Healthcare Provider (Hospital)
General Information
Principal Photograph
Max. size: 80.0 MB
Enrollee Registration No.
Name of Principal Enrollee (surname, First name, others).
Residential address
State
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: 80.0 MB
Dependent Child 1
Surname
First name
Middle name
Date of Birth
Sex
Genotype
Blood Group
Hospital Chosen
Dependent Child 1 Photograph
Max. size: 80.0 MB
Company Information
Name of Company
Branch
Department
Employer’s Authorized Signature
Max. size: 80.0 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
Choice of Healthcare Provider (Hospital)
Input Healthcare Provider (Hospital)
General Information
Principal Photograph
Max. size: 80.0 MB
Enrollee Registration No.
Name of Principal Enrollee (surname, First name, others).
Residential address
State
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: 80.0 MB
Dependent Child 1
Surname
First name
Middle name
Date of Birth
Sex
Genotype
Blood Group
Hospital Chosen
Dependent Child 1 Photograph
Max. size: 80.0 MB
Company Information
Name of Company
Branch
Department
Employer’s Authorized Signature
Max. size: 80.0 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,.