Please note all beneficiaries on one membership to be under same scheme as applicant

MEDICAL HISTORY

Please complete the questions below as accurately as possible. It is important to disclose all pre-existing conditions. Failure to disclose material information or provision of incorrect information may result in immediate suspension or cancellation of membership or benefits. The questions below applies to the Principal member all the beneficiaries covered under this membership application. Have any of the applicants suffered from any of the following conditions.

Any other condition not stated above. If yes please give detail in the table below.

If you have ticked YES for any of the above, please complete the section below. Please disclose all the important information.

DECLARATION BY PRINCIPAL APPLICANT

I declare that any false information in the above questionnaire or the non disclosure of any material information will render the membership null and void.

1. I understand that any condition for which I or any of my dependants have received medical advice or treatment in the last three months may be excluded from benefits
   offered under the scheme.
2. I understand that I or any of my registered 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.
3. I authorize Advantage Health to have unrestricted access to my medical records but require their confidentiality to be maintained
4. I have completed the medical history for myself and all my dependants as declared in this form
5. I consent to the use of any of the contact details given in this application to send me information pertaining to my policy (confidential or other).
6. I undertake to inform the Advantage Health of any change of address and contact details. The Society shall not be held liable as a result of my neglecting to inform the.
   SOCIETY of any changes to the aforementioned.
7. I consent to my telephone conversations with the Society being recorded and forming part of the Society’s records. I also agree that such records shall remain the sole property of the Society
8. I consent to Advantage Health marketing products, services and special offers being sent to me from time to time.
9. I consent that any Third Party contracted to perform services relating to Advantage Health cover may contact me from time to time regarding their products and services.