Health Insurance Form

     

Name (Insured):

   *
     

CPR Number

  
     

Address

  
     

Mobile

   *
     

Email

   *
     

Fax

  
     

Nationality

  
     
 

Have you been previously covered by R&SA or Mednet?

 Yes No  
           

Marital Status

No of Children

Active at work since
 
Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating :
 

1. Infectious and parasitic diseases

 Yes No  

10. Disease of genitourinary system, kidney diseases and breast disorders.

 Yes No
         

2. Neoplasms/Cancer (benign or malignant)

 Yes No  

11. Pregnancy, complication of pregnancy, child birth and the puerperium incl. abortion

 Yes No
         

3. Diseases of endocrine system, nutritional metabolic diseases and immunity disorders, diabetes

 Yes No  

12. Disease of the skin and subcutaneous tissue

 Yes No
         

4. Diseases of blood and blood forming organs

 Yes No  

13. Disease of the musculoskeletal system and connective tissue

 Yes No
         

5. Mental /psychiatric disorders

 Yes No  

14. Congenital anomalies, hereditary/genetic diseases.

 Yes No
         

6. Diseases of the nervous system and sense organs (ear, eyes, nose)

 Yes No  

15. Certain conditions originating in the perinatal period

 Yes No
         

7. Disease ofthe cardiovascular system incl. hypertension

 Yes No  

16. Injury and poisoning

 Yes No
         

8. Disease of the respiratory system

 Yes No  

17. Previous medical/surgical hospitalisation , procedures and operations

 Yes No
         

9. Disease of digestive system

 Yes No  

18. Any (chronic) disease(s) , symptoms and complains not mentioned above

 Yes No
 

In case the answer is YES to any of the conditions/diseases above or in case any medication is required on o regular basis, please specify full details on a separate sheet. You may be asked to complete a further "Personal information" sheet and supply additional information by o Medical Physician).

I hereby declare and agree, with respect to both myself and to my dependants, that I am aware of the general terms of the insurance and I accept them.

I authorize my doctor, health institute or other organization 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, and treatment. A photocopy of authorization has the same validity as the original.