Comprehensive

Ultra-Med Health Care

Specialized Application Form Available

$40/month

$20,000 limit

Individual/Family

Dental

Optical

View Details

Ultra Med Health Care

APPLICATION FOR NEW MEMBERSHIP

Important: Please complete this application in BLACK INK using CAPITALS. Read the Terms & Conditions and Checklist at the back of the form.

PRINCIPAL MEMBER DETAILS

Required

Title *

Full Name *

ID/Passport Number *

Gender *

Date of Birth *

Address

Postcode

Next of Kin Name

Next of Kin Title

Phone Number *

Email Address

PARTNER DETAILS

Title

Full Name

ID/Passport Number

Gender

Date of Birth

DEPENDENTS DETAILS

No dependents added. Click "Add Dependent" to add family members.

SELECTING YOUR PLAN

Please select which scheme you are applying for *

PRE-EXISTING CONDITIONS

Do you or any of your dependents suffer from any of the following medical conditions? If yes, tick the appropriate box and provide details below.

Arthritis

Asthma

Cancer

Disorder of the ear, nose or eye

Orthodontics

High blood pressure

PREVIOUS MEDICAL AID

Previous Medical Aid 1

Name

Level

Membership Number

Start Date

End Date

TERMS AND DECLARATION

General Terms and Conditions:

• The general waiting period for accessing basic medical care is 3 months.
• 9 months waiting period applies to all new policies.
• 12 months initial waiting period for optical costs and 3 year waiting period thereafter.
• 6 months waiting period for dental care.
• 12 months waiting period for all foreign specialist care.
• Maximum of 12 visits per annum for specialist consultants.
• 2 year waiting period for pre-existing medical conditions.

I agree to abide by the Rules and Regulations by Ultra-Med Health Care. *

By checking this box, you agree to the terms and conditions outlined above.

I declare that the information provided in this form is true and accurate. *

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

Important Information

All information provided will be kept confidential
You will receive a confirmation email after submission
A representative will contact you within 24 hours
No obligation to purchase
This form is specifically designed for Ultra Med Health Care applications

Need Help?

Our team is here to help you choose the right medical aid plan for your needs.