Enrollee Registration - VERITAS HEALTHCARE LTD

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NEW ENROLLEE REGISTRATION

You can also click download PDF form and complete it manually, then send it to forms@vhcl.com.ng

To be completed in CAPITAL LETTERS Please complete the form as appropriate. Note the red asteriks * for the required fields. Thank you for chosing Veritas Healthcare Ltd.
Photo:* (required jpeg, png less than 2MB)
Title:	Full Name:*
Sex:* Marital Status:*	Date of Birth:* dd/mm/yyyy (e.g. 23/11/2012)
Phone:* State of Posting	Email:*
Employer Staff ID:
Employer Name:*
Employer Address:*
Health Plan:*
CHOICE OF HOSPITAL
Preferred Health Facility (Hospital):*
Alternate Health Facility (Hospital): (Selected only if dependants are in a different location) Please Tick the box below if using alternate Healthcare Facility SpouseChild 1Child 2Child 3Child 4

Do you have Dependant(s)? NoYes

DEPENDANT(s) DETAIL
Spouse Photo:
Sex:	Spouse Name:	Date of Birth: dd/mm/yyyy (e.g. 23/11/2012)

Do you have Children? NoYes

CHILDREN DETAIL
Child 1 Photo:
Sex:	Child 1 Name:	Date of Birth: dd/mm/yyyy (e.g. 23/11/2012)

Add another Child? NoYes

Child 2 Photo:
Sex:	Child 2 Name:	Date of Birth: dd/mm/yyyy (e.g. 23/11/2012)

Add another Child? NoYes

Child 3 Photo:
Sex:	Child 3 Name:	Date of Birth: dd/mm/yyyy (e.g. 23/11/2012)

Add another Child? NoYes

Child 4 Photo:
Sex:	Child 4 Name:	Date of Birth: dd/mm/yyyy (e.g. 23/11/2012)

This is the last, you are allow to add only 4 children in a plan. Thank you.

Note: The Information provided shall be kept with utmost confidentiality and shall be used for no other purpose than HMO Registration.

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2nd Floor, Veritas Kapital Building, Plot. 497 Abogo Largema Street, Off Constitution Avenue, CBD Abuja.

Credit: Qreative Landscaper

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