PARADISE HEALTH CLIENT FORM (2013-page1)

PARADISE HEALTH CONSULTANCY 3F VCFI Bldg., 36 Archbishop Reyes Ave., Cebu City 6000, PH Ph. Tel. No. (032) 266 1342 E-mail: info@paradisehealth.co; Website: www.paradisehealth.co

Attach 1x1 colored photo taken not more than 6 months ago

CLIENT FORM FOR PARADISE HEALTH APPLICANTS (Entries must be written clearly; check appropriate boxes) Last Name First Name Alias (AKA) Religion

Gender Male Female Civil Status Single Passport No.

Date of Birth

Place of Birth

Nationality ID No.

Married

Divorced Widowed Place of Issue

Height Date of Issue

Weight Valid Until

Home Country Address (please specify)

Telephone No.

Fax No.

Mobile No.

E-mail Address

Primary Address in the Philippines (please specify) If no primary address, do you want to avail of our accommodation assistance? Yes No Telephone No. Fax No. Name of Contact Person in Case of Emergency Contact No. Address MEDICAL HISTORY Blood Type Medications (Present) Past Illness Hospitalization History Desired Medical/Dental Care Do you have any health insurance? If Yes, Name of Insurance Company ________________________________________________ Maximum Insurance Coverage Amount ________________________________________ PLEASE READ CAREFULLY: 1. Paradise Health Consultancy is not liable in case of death, misdiagnosis, worsening of medical condition, and/or other injuries. 2. Paradise Health Consultancy does not guarantee entry into the Philippines. Please check Philippine Immigration website at www.immigration.gov.ph for excluded aliens. 3. Honouring of the applicants health insurance by the physician is not guaranteed. 4. The participation of Paradise Health Consultancy is limited only to the giving of assistance to the applicant. 5. The applicant can only avail of the services of Paradise Health Consultancy upon full payment of the service charge of K595 for the first month. 6. The service charge due to Paradise Health Consultancy is non-refundable. By affixing my signature here, I hereby certify I have understood all the terms and conditions presented above and that the information written are true and correct and any misrepresentation on my part will be grounds to disapproval of the application. (For Paradise Health Consultancy Use Only) Receiving Personnel: _________________________________________________ Signature over Printed Name/Date Yes No Cardiology Orthodontics Cosmetic Surgery Dermatology Diagnostics Dentistry Orthopaedics Ophthalmologist Executive Check-Up Others, please specify ________________ Allergies

Mobile No. Nationality

E-mail Address Relationship

Date Signed: -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Proof of Application Date of Application: __________________________ Documents Submitted: _____________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Comments/Remarks: _______________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________