Dependent Registration Dependant Membership Form Passport Picture * Drop a file here or click to upload Choose File Maximum upload size: 3MB First Name * Last Name * Other Names Date of Birth * Sex * Male Female Tel No. Are you registered under NHIS? * Yes No If yes, NHIS No. Principal Member’s Name * Principal Member’s Company * Relationship to Principal Member * Medical History (Kindly select as many as apply to you) * Heart Attack Heart Murmur Extra/Skipped Heartbeats Frequent Breathing Difficulty Frequent/Abnormal Shortness of Breath Abnormal Electrocardiogram (ECG or EKG) Any Other Heart Trouble Disease of the Arteries Varicose Veins Phlebitis (Inflammation of a Vein) Arthritis (Legs, Arms, etc.) Frequent Leg Cramps Leg Frequent Swelling/Painful Knees or Ankles Swollen/Stiff/Painful Joints Leg Pains After Walking Short Distances Diabetes/Abnormal Blood-sugar High Cholesterol Level Dizziness/Fainting Spell Increased Anxiety or Depression Migraine/Recurrent Headache Epilepsy/Seizures Spectacles Rheumatic Fever Cold Hands/Feet even in hot weather Abdominal Aortic Aneurysm Critical Aortic Stenosis Chronic/Recurrent/Morning Coughs Coughing up Blood Significant Vision/Hearing Problems Glaucoma/Increased Pressure in Eyes Exposure to Loud Noises for Long Periods Recent Change in a Wart/Mole Recurrent Fatigue/Trouble Sleeping/Increased Irritability Stomach/Intestinal Problems such as Recurrent Heartburn/Ulcers/Constipation/Diarrhoea Foot Problems including Hammertoes/Blisters/Bunions/Ingrown Toenails/Toenail Fungus Kindly select as many as apply to you – press and hold ctrl key to select multiple Disclaimer Declaration By submitting this form, you confirm to the best of your knowledge and belief that the information you have provided is accurate and truthful. The information you have provided will be processed according to our privacy policy. Any false information provided on this form will result in the refusal of your application or termination of your membership and any payments made on your behalf shall be demanded. I confirm that I have read and understood the terms above. Sign * (For Children, Principal Member should sign on their behalf). Please type your name. Submit