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HEALTH REDEEM COVER
Email address *
AFFORDABLE ALTERNATIVE TO HEALTH INSURANCE
First Name: Surname:
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Date of Birth: *
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BVN Number:
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Address:
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Occupation:
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Telephone Number:
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Sex:
Genotype
Do you or have you ever suffered from any of the following ailments? If so, please indicate.
Hav you ever had a surgical operation?
Do you have any Allergy?
If ''Yes'' to Allergy questio, please indicate below.
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Are you pregnant? or planning to get pregnant?
Are you on any prescribed medications?
Do you drink alcohol
Please state any other relevant information you would like us to have concerning your health
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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:
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34 Uwa Street, Between 2nd & 3rd East Circular Road, Benin City. Edo State Nigeria.Telephone: 002347058964321 UK & Other Europe: 00447480889884 Email: healthredeemcovers@gmail.com www.healthredeemcovers.com
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