Family Care Plan

Emirates ID
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Emirate ID
Date of Birth
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NameEmirate IDDOBNationalityResidance Visa / EmiratesGenderHeightWeightRelationScan EidAdd/Del

1Is there any eligible family member kept away from this insurance request?
2Have you availed insurance services under MedNet earlier?
3Has your health insurance request ever declined or accepted on substandard terms?
4Are you under any medical observation/undergoing any medical/ surgical/ treatment or have been advised for the same?
5Do you have any chronic illness? A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics: It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests. It needs ongoing or long-term control or relief of symptoms. It may require rehabilitation or the patient to be trained to cope with it. It continues indefinitely. Symptoms / medical condition may recur or likely to recur.
6Are you taking any medication (pharmaceutical/alternative medicine) or have been advised?
7Do you have any physical problems/ disability for which you are undergoing physiotherapy or have been advised for?
8Have you been admitted in the hospital in the last 10 years?
9This question applies only to eligible married females. Are you currently pregnant - show signs and/or symptoms of pregnancy - planning to get pregnant? Please fill the attached supplementary maternity questionnaire "Page 3"
10Do you have any previous surgical history or are you advised to undergo any kind of surgeries in the near future?
11Have you been ever diagnosed/treated and cured or undergoing treatments for cancer?
12Is there any other medical condition or disorder or any symptoms that you should be declared, and you are unable to relate to the above-mentioned Questions?
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