Transcription of APPLICATION FOR ADDITIONAL DEPENDANTS - …
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APPLICATION FOR ADDITIONAL DEPENDANTS - …
Grintek ElectronicsMedical Aid SchemeUniversal House15 Tambach RoadSunninghill Park, SandtonTel: 011 208 1000 Administered by:UNIVERSAL HEALTHCARE ADMINISTRATORS (PTY) LTDReg. No. 1974/001443/07 Private Bag X1897 Rivonia2128 Fax: 011 208 1028 Identity number:TO BE COMPLETED BY MEMBERAPPLICATION FOR ADDITIONAL DEPENDANTS Member s surname:First name/s:Principal member:Membership number:Company/Division:SurnameFirst names/sIdentity numberRelationshipDate of birthAdditional dependant/s:Dependant/s to be registered as from:Did your dependant belong to a previous medical aid? If yes, please attach a membership History: (NB - Not to be completed when dependant is newborn) The answer to these questions, which will be treated as confidential, and should be as detailed as is most important that the questions on the following page be answered as thoroughly as possible.
YES NO Name of member/dep. 6. Urinary Tract Infections; stones; albumin/blood in urine; urinary incontinence; prolapsed bladder. 7. Gynaecological System Menopause, female hormone replacement, irregular menses; infertility; breast tumours
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