Medical Application Form PDF

Medical Application Form
Insured Name: Inception Date:

Required Plan: Policy No.:
Photo
NAME please specify Employee (E), Child (C) or Spouse (S) Relation D. O. B. Nationality Sex Height Weight card Bahraini
Resident
First Name Middle Name Family Name E/S/C DD/MM/YY M/F CM KG Yes/No
Has MedNet previously covered any of the above applicants? Yes No

Is there a member in your family that is not proposed for Insurance? Yes No If Yes, please explain under section Comments
Marital Status: No. of Children: Active at work since:

Street: City:
P.O. Box: Tel. No:
I hereby declare and agree, with respect to both, myself and to my Dependants, that I am aware of the general terms of this insurance and I
accept them. With the above, I authorise my doctor, health institution or other organisation or person that has any information about my health
and/or activities (and those of my Dependants) to provide the Insurer with the said information. This shall include hospital and any other records
pertaining to medical advice, diagnosis, treatment or disturbances. A photocopy of this authorisation has the same validity as the original.
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms
indicating:
(Please tick relevant box) Yes No Yes No

1. Infectious and parasitic diseases 10. Diseases of genitourinary system, kidney diseases
and breast disorders
2. Neoplasms/Cancer (benign or malignant) 11. Pregnancy, complications of pregnancy, child birth and
the puerperium incl. abortions
3. Diseases of the endocrine system, nutritional-, 12. Disease of the skin and subcutaneous tissue
metabolic diseases and immunity disorders, diabetes
4. Diseases of blood and blood forming organs 13. Diseases of the musculoskeletal system and
connective tissue
5. Mental-/psychiatric disorders 14. Congenital anomalies, hereditary/genetic diseases
6. Diseases of the nervous system and sense organs 15. Certain conditions originating in the perinatal period
(ears, eyes, nose)
7. Diseases of the cardiovascular system 16. Injury and poisoning
incl. hypertension
8. Diseases of the respiratory system 17. Previous medical/surgical hospitalisations, procedures
and operations
9. Diseases of digestive system 18. Any (chronic) disease(s), symptoms and complaints not
mentioned above
In case the answer is YES to any of the conditions/diseases above please specify full details (preferably by a Medical Physician) on the additional
questionnaire (Personal Information), which will be found attached to this application form.
In case medication is required on a regular basis please specify the full details such as genuine name, brand name and daily/weekly quantity on
the additional questionnaire (Personal Information), which will be found attached to this application form .
MedNet Bahrain W.L.L.

P.O. Box 21643, Manama – Kingdom of Bahrain
Tel.: +973 175 66 175 Fax: +973 175 83 006 E-mail: [email protected] Web: www.mednet-bahrain.com
Comments:
Only to be filled out if you have answered “Yes” in the question of any family members, who is not proposed for
Insurance.
I agree that no indemnity will be paid under the proposed insurance policy for medical expenses arising from
disorders which were declared prior to completion of this Application and which were not disclosed to the insurer at
the date of this application. Failure to disclose material information to the insurer will invalidate the proposed
insurance policy.
I hereby agree, with this in respect to both, myself and my Dependants that I am aware of the general terms of this
insurance and I accept them for myself and on behalf of my dependants. I the undersigned declare that all of the
above information as well as all declarations on the additional questionnaire (personal information) are true and
complete. This information shall be considered as an integral part of the insurance policy.
Date: Signature:

Medical Conditions
Name of applicant Age: Sex:

Date of application: / / (dd/mm/yyyy)
Medical condition/diagnosis:
(if more than one sickness, please complete a separate form for each)
Date of last treatment/symptoms: / / (dd/mm/yyyy) ongoing treatment = current date
Diagnosis Status: Yes No

Cured/ no symptoms
Ongoing symptoms
Ongoing hospitalization
Pending hospitalization
Ongoing treatment
Pending treatment
In case of any Diagnosis Status the applicant was treated as:

Outpatient
Hospitalized
Treated both ways
Operated on: / / (dd/mm/yyyy)
How often do the symptoms occur?

Or can the illness be described as follows?
Acute
Chronic
Recurrent
Did you have any bone fractures or injuries to bones or tendons?

Has any material used for osteosynthesis etc. been removed?
In case medication is required on a regular basis please specify the genuine name,
the brand name as well as the daily/weekly quantity below.
In case you are suffering from hypertension please specify your Systolic and Diastolic readings below.
Systolic:
Diastolic:
In case of diabetes please specify whether insulin dependent.
Date: Signature:
Absa bank Dr K.E MORABA 9336908020


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Medical Application Form

Insured Name: Inception Date:

Has MedNet previously covered any of the above applicants? Yes No

Marital Status: No. of Children: Active at work since:

(Please tick relevant box) Yes No Yes No

MedNet Bahrain W.L.L.

MedNet Bahrain W.L.L.

Name of applicant Age: Sex:

Diagnosis Status: Yes No

In case of any Diagnosis Status the applicant was treated as:

How often do the symptoms occur?

Did you have any bone fractures or injuries to bones or tendons?

In case of diabetes please specify whether insulin dependent.

Absa bank Dr K.E MORABA 9336908020

MedNet Bahrain W.L.L.

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