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HEALTH REDEEM COVER
AFFORDABLE ALTERNATIVE TO HEALTH INSURANCE
First Name: Surname:
Date of Birth:
Do you or have you ever suffered from any of the following ailments? If so, please indicate.
Cold & Flu
Hearing & Ear
Hav you ever had a surgical operation?
Do you have any Allergy?
If ''Yes'' to Allergy questio, please indicate below.
Are you pregnant? or planning to get pregnant?
Are you on any prescribed medications?
Drug 1: Name & strength
Drug 2: Name & strength
Drug 3: Name & strength
Drug 4: Name & strength
Drug 5: Name & strength
Do you drink alcohol
Please state any other relevant information you would like us to have concerning your health
I hereby declare that all information given above are all true to the best of my knowledge and that I have not concealed or withheld any information. I also agree to abide by the terms and conditions of the Healthcare Scheme. Please sign and date in the space below:
34 Uwa Street, Between 2nd & 3rd East Circular Road, Benin City. Edo State Nigeria.Telephone: 002347058964321 UK & Other Europe: 00447480889884 Email:
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