Pro Senior Application Frorm

Pro Senior Membership Application Form

    ACCOUNT HOLDER DETAILS

  • Type Of Membership

  • Principal Member Details

  • Contact Details

  • Please Select Which Plan You Wish To Join

  • Dependent

  • Please ignore this section if you do not have any dependants.
  • Additional Benefits

  • Details of Previous Medical Aid Society

  • Please Note that you will be required to provide a Certificate of Membership of Last Medical Aid Society if any. Leave This section blank if it is not applicable.
  • Preferred Payment Method

  • Bank or Mobile Money Account Details

  • Medical History

  • Pre-existing conditions may be excluded from benefit. Please read carefully and select the appropriate box below. If the answer is "YES"to any of the conditions, please provide details in the space provided in respect of each person registered. Failure to disclose material information or disclosing incorrect information can result in immediate cancellation of membership or benefits.
  • Have you, your spouse or any of your dependants suffered from any of the following:

  • Declaration and Submission

  • 1. I hereby acknowledge that all the information provided above is accurate and correct. 2. I understand that failure to disclose any condition for which I or any of my dependants have received medical treatment for may result in exclusion from benefit in terms of the Society's rules. 3. I understand that I or any of my dependants may be required to obtain a medical report or undergo a medical examination to provide further information on any of the conditions declared above. 4. I authorise Pro Health Medical Aid Society to have unrestricted access to my medical records but require confidentiality to be maintained. 5. I have completed the medical history for myself and my dependants declared in this application. 6.I hereby acknowledge that I have read and understood the full Pro Health Terms and Conditions here : http://prohealth.co.zw/terms-and-conditions/
 

Verification