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The PHL enrollee form, is your first step to world class health management with Prohealth HMO.

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Download – PHL ENROLEE REG FORM

ENROLLEE APPLICATION FORM

PIC UPLOAD *
HEALTH PLAN *
TYPE: *
FULL NAME(Starting with Surname) *
SEX
DATE OF BIRTH *
MARITAL STATUS *
NATIONALITY *
NAME OF ORGANIZATION *
Phone *
GENOTYPE
BLOODGROUP
EMAIL OFFICIAL/PERSONAL
CONTACT ADDRESS
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
HOSPITAL OF CHOICE *Please, check the list of hospital as declared.
BRIEF MEDICAL HISTORY e.g Pre-exiting condition
Check any belowHYPERTENSIONASTHMADIABETESSICKLE CELLCANCERAIDSGLAUCOMAPREGNANCY
PREVIOUS SURGERY(IES) & ALLERGY(IES)

DEPENDANTS FORM SECTION

SPOUSE PASSPORT
SPOUSE FULL NAMES(Starting with Surname first)
SPOUSE DATE OF BIRTH
SPOUSE SEX
SPOUSE PHONE DETAIL;
SPOUSE EMAIL ADDRESS
SPOUSE BRIEF MEDICAL HISTORY e.g Pre-existing condition kindly state for examples, Hypertension, Asthma, Diabetes, Sickle cell, Cancer, Aids, Glaucoma, Pregnancy etc.
FIRST CHILD PASSPORT

FIRST CHILD

FIRST CHILD FULL NAME(Surname First)
DATE OF BIRTH
SEX:
BRIEF MEDICAL HISTORY e.g Pre-existing condition if any
SECOND CHILD PASSPORT

SECOND CHILD

SECOND CHILD FULL NAME(Surname first)
DATE OF BIRTH
SEX
BRIEF MEDICAL HISTORY e.g pre-existing condition if any
THIRD CHILD PASSPORT

THIRD CHILD

THIRD CHILD FULLNAME(Surname First)
DATE OF BIRTH
SEX
FOURTH CHILD PASSPORT
BRIEF MEDICAL HISTORY e.g Pre-existing condition if any

FOURTH CHILD

FOURTH CHILD FULLNAME(Surname first)
DATE OF BIRTH
SEX
BRIEF MEDICAL HISTORY e.g Pre-existing condition if any.

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