Husband (Title)

First Name

Surname

Date of Birth

Wife (Title)

First name

Surname and Maiden Name

Date of Birth

Address Postcode

Email Address

Home Telephone:

MOBILE NUMBER:

Doctors Name:

Doctors Address:

Doctor Telephone:

Attending or receiving treatment from a doctor, hospital, clinic, or specialist

YESNO

Taking any medication from your doctor? (Tablets, creams,injections, liquids)

YESNO

Taking steroids, or have taken them in the last two years?

YESNO

Any other aspects concerning your health we should know about?

YESNO

Any other information

Name

Date

Signature

i) I hereby confirm that the information provided above is true and accurate to the best of my knowledge.
ii) I acknowledge that any failure to disclose facts that are or may be material to my medical history, and / or any inaccuracies in the information I have provided, may invalidate my Membership in the Areivim UK scheme and / or disallow any benefit to be derived from the Membership by the Member or any third party.
iii) I acknowledge that Areivim UK may at their sole discretion request, at any time ‐ either during the Membership term or anytime thereafter, either from myself as the Member or the beneficiary of the Membership, information to substantiate the answers provided above, which may include the Medical Records of the Member. Any failure to provide this information may result in invalidating my Membership and / or disallow any benefit to be derived from the Membership by the Member or any third party