BIOMETRICS FORM

Valley View Plaza 99, Opebi Road, Ikeja, Lagos.

Tel: 01- 2790698, 08021210747 Fax: 01-2790698

Plan Type (Tick) Individual Family

Surname Other Names ______________________________ _______

Residential Address __________________________________________________________________________________

Mobile Phone ____________________________________ Position ________________________________________

Date of Birth _____________ Sex ____________ Marital Status ___________ Blood Group _________________

Employer _______________________________________________________ Genotype ________________________

Health Plan (Tick) Bronze

Bronze Silver Silver Gold Gold Platinum
Bold Special Plus
Selected Hospital ____________________________________ Location ______________________________________

Preferred Start Date _____________________________ End Date __________________________________________

MEDICAL HISTORY OF SIGNIFICANCE

Have you or any of your family members been diagnosed with any of the disease below? Please tick as appropriate

Sickle Cell Disease Kidney Disease Epilepsy Cancer

Diabetes Mellitus Asthma HIV/AIDS Chest Pain
Hypertension Cataract Peptic Ulcer Peptic Ulcer
Hepatitis Glaucoma Tuberculosis Haemorrhoids

DEPENDANTS

ss
Spouse
Child 1 Child 2 Child 3 Child 4

_______________ ________________ _________________ ________________ _______________

Name
__________ __________
Date of Birth Sex
________ ___________
Genotype Blood Group
________ __________
Health Plan Signed
_____________________
Selected Hospital
Name Name Name Name
__________ __________ __________ ____________ __________ __________ __________ ________
Date of Birth Sex Date of Birth Sex Date of Birth Sex Date of Birth Sex
________ ____________ ________ ____________ ________ ____________ ________ __________
Genotype Blood Group Genotype Blood Group Genotype Blood Group Genotype Blood Group
_________ __________ _________ ____________ _________ ____________ _________ __________
Health Plan Signed Health Plan Signed Health Plan Signed Health Plan Signed
_______________________ ______________________ ____________________
Selected Hospital Selected Hospital

Drug Reaction/Allergies ______________________________________________________________________________

DECLARATION
I hereby declare that all information given above are true to the best of my knowledge and that no relevant information has
been withheld or concealed.

Signed ______________________ Date ________________________