PHILLIPS HMO ENROLLEE SUBSCRIPTION FORM

DATE: 2 0 0 1 2 0 2 2

E Z E H S O L O M O N O N Y E K A C H I TAFF PICTURE
SURNAME FIRST NAME OTHER HERE
NAMES
DD / MM / YY

Gender M F Marital Status SE I N G L E DOB: 2 8 / 1 1 / 8 7

Home Address: N O 7 N E W H E A V E N A N N E X A K P A J O
P O R T H A R C O U R T R I V E R S S T A T E

Town/City: PORT HARCOURT

PORT HAC OU RT Office Phone No: 0 9 0 8 8 2 5 7 5 2 9
State of Origin: E N U G U Nationality: N I G E R I A
E-mail: s o l z e e k s @ g m a i l . c oLom
cal Govt: U D I L G A
Telephone: 0 9 0 6 0 0 0 1 6 6 0 Staff ID/ No:

Company Name & Address: W E S T E R N B U C K L A N D I K E J A L A G

Designation/position: F I R L D M A I N T E N A N C E E N G I N E E R
NAME OF NEXT OF KIN: H E N R Y O G O C H U K W U E Z E H
Relationship: B R O T H E R Gender: M F Marital status:SINGLE

Address: NO 7 NEW HEAVEN ANNEX AKPAJO RIVERS STATE

Telephone No: 0 8 0 6 3 1 5 7 9 1 5 Office Phone No: 0 8 0 5 6 9 5 6 2 2 4
DEPENDENTS DETAILS: (if applicable) (Kindly write names at the back of each passport photograph)

AFFIX AFFIX CHILD’S AFFIX CHILD’S AFFIX CHILD’S AFFIX CHILD’S

SPOUSE’S PICTURE HERE PICTURE HERE PICTURE HERE PICTURE HERE
PICTURE HERE

SURNAME:

FIRST NAME:

MIDDLE NAME:

GENDER:

DATE OF BIRTH :

TELEPHONE:
PREFERRED PRIMARY PROVIDER AND PLAN

NAME OF MEMBER PREFERRED PRIMARY PROVIDER PLAN

EZEH SOLOMON DOMINGO SPECIALIST HOSPITAL AKO15 MEDICAL

PAST MEDICAL RECORD

Please provide correct answer to the questions below for the purpose of quality assurance (mark √ and give appropriate
details):

Question Yes No If yes provide Details

Are you or your dependent currently on any Drug?

Are you or your dependent pregnant? If yes what is the
Expected Delivery Date?
Do you or your dependent have any History of Allergy?

Do you or your dependent have any Pre-existing

Medical Condition (e.g. Hypertension, stroke, Diabetes,
Arthritis, Pectic Ulcer, Asthma, Sickle cell disease, Cancer,
Chronic neuro-muscular disease), etc?

Have you or your dependent been Hospitalized before?

Have you or your dependent had surgery done before?

APPENDICITIS

I affirm that the information provided herein in absolutely correct and that any false information or non -disclosure will
invalidate my subscription. I hereby give authorization to Phillips HMO to have access to all my medical record (past and
present). I also hereby acknowledge that I have read and understand and agree to be bound by the terms and conditions
of enrollment with Phillips HMO as well as the benefit package of the plan I am purchasing.

Signature of principal Date: 20/01/2022

Please attach a valid copy of your ID card

All completed forms and other correspondence should be sent to:

Address: 70B, Lanre Awolokun Street, Gbagada Phase 2, Gbagada, Lagos.

Email: info@phillipshmo.net, Telephone: 016339121