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Add a Dependant

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Re-order Full Name Date of Birth ID / Passport Number Relation to Main Member Weight Operations
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1. Shortness of breath, palpitations, raised cholesterol, stroke, raised blood pressure, heart murmur, angina, heart attacks or other cardiac/vascular disorder?
2. Difficulty when breathing, persistent cough, tuberculosis, asthma, bronchitis pneumonia, croup or Yes No any other related respiratory disorder?
3. Nephritis, prostrate problems, kidney stone, congenital kidney disorder, albumen in urine, uraemia or any other urinary/kidney disorder?
4. Diabetes, sugar in blood/urine, glandular, disorder, goitre or any other endocrine disorder?
5. Conditions of joints or spine including rheumatism, arthritic, neck or back disorder?
6. Any lumps, growths (benign or malignant cancer, Hodgkin’s disease, leukaemia, skin cancer, lesion or any other related problems?
7. Ulcers (gastric or duodenal hiatus, hiatus cancer, lesion or any other related problems dysenter y, gastro- intestinal or abdominal obstructions or any other related disorders?
8. Nervous or mental complaint e.g. epilepsy convulsions, dizziness, blackouts, paralysis meningitis, Yes No anxiety states, depression, alcoholism meningitis, anxiety states, depression, alcoholism
9. Ear, eye, nose, throat problem, including ear discharge, hearing loss, defective vision tonsillitis, grommets’, injuries, or any other ENt disorders?
10. Diseases of the reproductive system e.g infertility, ovarian cysts, uterine fibroids, abnormality of Yes No pregnancy or confinement or any other related reproductive system disorder?
11. Expecting or planning to have a baby? If you have indicated ‘yes’ please state the expected delivery dates
12. Sexually transmitted diseases e.g syphilis. gonorrhoea, HIV /aIDS related illness or any other Yes No sexually transmitted diseases?
13. Any physical disabilities or injuries?
14. Any congenital disease/disability?
15. Any special dental treatments e. crown bridge prosthodontic and orthodontic appliances or any other dental problems?
16. Are you a smoker or routine user of alcohol and other narcotics?
Re-order Member Type(e.g Principal Member, dependant) The relevant question Number from section 3 When last did you see your doctor and for what reason? Do you have any chronic conditions that may need medical attention within the next twelve months? List details of medications used in the last 12 months and related conditions? Weight Operations
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One file only.
2 GB limit.
Allowed types: pdf, doc, docx.
One file only.
2 GB limit.
Allowed types: pdf, doc, docx.
One file only.
2 GB limit.
Allowed types: pdf, doc, docx.

CLIENT INFORMATION CONSENT

In terms of the Data Protection Act, Bomaid is obligated to obtain the customer’s consent to acquire and process customer information. To provide performance of a contract to which the customer is a party, Bomaid might have to share the customer’s personal and sensitive data with authorized third parties such as service providers and consultants for processing. Our comprehensive privacy notice is available on our website.

I authorize Bomaid or any Bomaid contracted outsourced providers to collect, process, and request my personal and sensitive data from any healthcare service provider or person who has attended to me or my dependants in the past or who will attend to us in the future or who may be in possession of information about us, including our health status, treatment received or anticipated as well as any other relevant health information for any purpose directly related to our membership or which is authorized in terms of the Medical Schemes Act, the Scheme Rules, or any other legislation, also after the death or termination of membership of any of us.

I authorize Bomaid to deal with my dependants and me electronically and treat electronic communication (such as email, telephone, Bomaid’s digital App) as being the same as written authority and confirmation. I agree further that, where we choose to use electronic methods to transact with Bomaid, we will carry the risk of such use.

Bomaid may use my information for the purpose of marketing (including direct marketing) of its suite of products, benefits, and any other financial or non-financial services offered by itself and its subsidiaries.

I have the right to see any information that Bomaid holds about me, and to have my details removed.

I provide the consent of my own free will without any undue influence from any person whatsoever, and I understand that I can withdraw my consent in writing at any time. The grounds for withdrawing consent should be legitimate, reasonable, and compelling.

The Fund may send your personal information to service providers outside Botswana for the storage or further processing on behalf of Bomaid. Bomaid will ensure to adhere to the provisions of the Data Protection Act before such transborder transfer of your personal information.