Applicant Details

Partner and Dependents Details
Induvial Plans
Pre-Existing Conditions
Individual packages do not cover chronic conditions
l declare that the information provided in this form is true and signing the application form, forms the basis of a contract accurate. Should my application for membership be accepted, between myself and Ultra-Med health. l agree to abide by the Rules and Regulations by Ultra-Med Health Care.

l certify that none of my dependents or myself suffer from any condition(s) not stated on the form. l hereby authorize Ultra-Med health to access my medical record from any health service provider for any reason whatsoever.

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