Membership Form Central Health 5 Membership Form SelectMember Name:MrMrsMsDrProfRevH.EName:Gender:MaleFemaleDate of Birth:Nationality:ID Number:Marital Status:Phone:Email Address:Occupation:EmployedSelf EmployedNot EmployedEmployer’s Name:Type of Business:Employer Address:Department:Position:Location:Your Age *0-5 years6-59 years60-69 years70-74 years75 and aboveSelect Your Age Between This RangeDo you have any chronic disease conditions? *YesNoPlease answer correctlyPlan For 0-5 Years *DiamondDiamond PlusEmeraldFor 0-5 years, only Emerald Plan is availblePayment Plan *MonthlyAnnualPlan For 6-59 years *DiamondDiamond PlusEmeraldChoose Your PlanPayment Plan *MonthlyAnnualPayment Plan *MonthlyAnnualPayment Plan *MonthlyAnnualPlan For 60-69 years *DiamondDiamond PlusEmeraldFor 60-69 years, only Emerald Plan is availblePayment Plan *MonthlyAnnualPlan For 70-74 years *DiamondDiamond PlusEmeraldFor 70-74 years, only Emerald Plan is availblePayment Plan *MonthlyAnnualPlan For 75 and above *DiamondDiamond PlusEmeraldFor 75 and above, only Emerald Plan is availblePayment Plan *MonthlyAnnualPlan For All Range of Ages *Emerald PlanPayment Plan *MonthlyAnnualWhich of the chronic disease conditions? *High blood pressureDiabetesAsthmaAllergiesKidney illnessJoint conditionsCancer of any kindProstate issuesPregnancyGoutEye conditions/GlassesMental conditionsHIV relatedHepatitisAlcohol consumptionSmokingBlood conditionsBone conditionsChest/Lung conditionsStrokePhysiotherapy requiring conditionsCongenital abnormalitiesWhich of the chronic disease conditions? *High blood pressureDiabetesAsthmaAllergiesKidney illnessJoint conditionsCancer of any kindProstate issuesPregnancyGoutEye conditions/GlassesMental conditionsHIV relatedHepatitisAlcohol consumptionSmokingBlood conditionsBone conditionsChest/Lung conditionsStrokePhysiotherapy requiring conditionsCongenital abnormalitiesTotal PriceMKTotal PriceMKTotal PriceMKPaid By:CashChequeMobile TransferOnline TranferStanding TransferSend Message
