AVON HMO Registration

AVON Health Care Registration Form

Application Process

Step 1: Sponsor Details

HealthPlan: *

SponsorName: *

SponsorPhoneNo: *

SponsorEmail: *

Step 2: Child Details

ChildAccountNo: *

Surname: *

Firstname: *

Othernames: *

Date of Birth: *

Sex: *

HomeAddress: *

Town: *

LGA: *

State: *

Telephone Number: *

Email: *

HospitalName: *

Passport (upload a picture in format jpg, png, bmp | maximum filesize is 5mb): *

Step 3: Questionnaire

Medical Conditions

Do you have or have you suffered from any of the underlisted conditions (If Yes, Tick box | If No, Leave empty)

Chest pain / Angina or heart attack?

High blood pressure (hypertension)?

Lung/respiratory condition e.g. asthma, bronchitis, emphysema?

Stomach / bowel disorder e.g. peptic ulcer or diverculities or ulcerative calitis?

Urinary or kidney disorder e.g. kidney stones, urine incontinence?

Recurrent urinary tract infections or any requiring dialysis?

Muscle / bone or joint disorder e.g. bone fractures, osteoporosis, gout or arthritis?

Diabetis which is controlled by insulin drugs and / or diet?

Prostrate disorder?

Epilepsy or seizures?

Depression or schizophrenia or bipolar or other mental health conditions or drug or / and alcohol dependency?

Blood disoreder e.g. sickle cell anemia or thalassemias or G6PD?

Disease of the eye or nose or throat lasting longer than six months?

If yes, please give details *

Cancer that has been partially or totally treated?

Congenital abnormalities?

Surgical History

Have you suffered from any condition requiring, or have been recommended for surgery in the last twelve months?

General Questions

Have you tested positive for HIV/AIDS?

Have you experienced any of the following unexplained weakness, weight loss, diarrhea, skin lesions or enlarged nymph nodes?

Do you take any prescription medications for periods longer than one month?

If yes, what drugs*

Has there been any change in any of your prescription dosage/s?

If yes, please explain *

Have you received any new prescription, investigation or new medical consultation in the last 6 months?

Have you ever been tested or treated for infertility?

Step 4: Declaration

Any misrepresentation or non-disclosure of material or factual information will render all obligations under the scheme null and void. In addition, any payment made by Avon HMO will recoverable from the member.

All health plans take effect on the 1st day of the next month, when registration is completed before the 20th of the month. Any registration after the 20th of the month, will be effective on the first of the following month

I accept the Terms and Conditions: *