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plot 69-71 buganda road, kampala
+256 701 250362
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Home
About Us
Packages
Individual Packages
Family Cover
Corporate Cover
Antenatal Package
Elderly Cover
Hypertension Cover
Hypertension and Diabetes
Medical Checkup Programmes
Health Networks
Apply Online
Contact Us
+256 701 250362
plot 69-71 buganda road, kampala
Hypertension Cover Application Form
MEDICAL ENROLMENT FORM.
FirstName
LastName
Date of Birth
Gender
Male
Female
Blood Group
Business Address
Residential Address
Next of Kin
Telephone number - Home
Telephone number - Mobile
Telephone number - Office
DEPENDANTS DETAILS Please complete the following for your dependants. If there are more than 5 dependants then please complete a separate form for the others:
DEPENDANT 1
FirstName
LastName
DOB
Sex
Male
Female
DEPENDANT 2
First Name
Last Name
DOB
Sex
Male
Female
DEPENDANT 3
First Name
Last Name
DOB
Sex
Male
Female
DEPENDANT 4
First Name
Last Name
DOB
Sex
Male
Female
DEPENDANT 5
First Name
Last Name
DOB
Sex
Male
Female
DEPENDANT 6
First Name
Last Name
DOB
Sex
Male
Female
MEDICAL DECLARATION (for self and Dependants) Please indicate by ticking if you or any members of your immediate family have suffered /are suffering from any of the following:
Diabetes
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
Cancer
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Hypertension
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Sickle Cell Disease
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Bronchitis or Asthma
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Rheumatic fever
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Malaria
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Tuberculosis
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Hepatitis B
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Any STDs
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Any Allergies
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Any serious injury
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
Any operation in the last 5 years
SELF
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
NONE
If there is any of your dependant or yourself with any of the conditons above, please give details.
SERVICE AGREEMENT Case Medcare hereby agrees to provide and the Client hereby agrees to utilize the medical services of the Hospital at its above address. Case Medcare hereby warrants that it will diligently provide such services to the Client to the best of its ability using accepted scientific methods as and when required to do so by the Client. The Client hereby undertakes to pay for any additional services rendered to him which exceed the financial limits of the contractual terms. The Client hereby understands that membership fees are not redeemable 60 days after inception of cover. If termination, for whatever reason occurs within 60 days, membership fees are refundable, less the cost of treatment received by the Client during that period plus an administrative charge of 5% of the membership fee.
Signed by the Client:
Date
Signed & Stamped by; Case Medcare
Date
Send