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Antenatal Cover | MEDICAL ENROLLMENT FORM.

Please complete the following information as fully in block letters.

Please indicate the package

Individual Antenatal Individual Maternity

PRE-NATAL CARE QUESTIONNAIRE:

1. How many weeks or months pregnant are you since you had a pregnancy test or a doctor or nurse said you were pregnant?

2. How many prenatal visits have you so far done during this pregnancy?

3. Is this your first pregnancy?

No Yes

If No,
4. Did you have any of these problems during your last pregnancy? For each item, tick (Yes) if you had the problem or (No) if you did not

A). High blood sugar (diabetes) that started before the pregnancy

No Yes

B). High blood sugar (diabetes) that started during the pregnancy

No Yes

C). Vaginal bleeding

No Yes

D). Kidney or bladder (urinary tract) infection

No Yes

E). Severe nausea, vomiting, or dehydration

No Yes

F). Cervix had to be sewn shut (incompetent cervix)

No Yes

G). High blood pressure, hypertension (including pregnancy-induced hypertension [PIH], preeclampsia, or toxemia)

No Yes

H). Problems with the placenta (such as abruptio placentae or placenta previa)

No Yes

I). Labor pains more than 3 weeks before my baby was due (preterm or early labor)

No Yes

J). Water broke more than 3 weeks before my baby was due (premature rupture of membranes [PROM])

No Yes

K). I had to have a blood transfusion

No Yes

L). I was hurt in a car accident

No Yes

5. If you are currently experiencing any of the above, please tell us which. (Indicate a,b,..)

MEDICAL DECLARATION (for self and Spouse) Please indicate by ticking if you or your spouse, are suffering from / being treated for any of the following:

Sickle Cell Disease

No Yes

Bronchitis or Asthma

No Yes

Rheumatic fever

No Yes

Any operation in the last 5 years (C/Section)

No Yes

If the answer to any of the above is YES, 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.

About:

CaseMedInsurance provides individual, family and group (corporate) health insurance plans. These plans are Client centered, Affordable, Safe and Effective in reducing the out of pocket payment burden that leads many households to financial catastrophe.

Antenatal Cover | MEDICAL ENROLLMENT FORM.

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