PARADISE HEALTH CLIENT FORM (2013-page1)

PARADISE HEALTH CONSULTANCY

3F VCFI Bldg., 36 Archbishop Reyes Ave., Cebu City 6000, PH Ph. Tel. No. (032) 266 1342 E-mail: info@paradisehealth.co; Website: www.paradisehealth.co Attach 2x2 colored photo taken not more than 6 months ago

CLIENT FORM FOR PARADISE HEALTH APPLICANTS (Entries must be written clearly; check appropriate boxes) Last Name Gender Male Female Civil Status Single Passport No. Date of Birth First Name Place of Birth Alias (AKA)

Application No.

Religion Nationality ID No.

Height Married Divorced Place of Issue Widowed Date of Issue

Weight

Valid Until

Home Country Address (please specify) Telephone No. Fax No. Mobile No. E-mail Address

Primary Address in the Philippines (please specify)

If no primary address, do you want to avail of our accommodation assistance? Yes No Telephone No. Name of Contact Person in Case of Emergency Fax No. Contact No. Address Mobile No. Nationality E-mail Address Relationship

MEDICAL HISTORY Blood Type Past Illness Hospitalization History Allergies

Medications (Present)

Desired Medical/Dental Care Cardiology Orthodontics Cosmetic Surgery Dermatology Diagnostics Dentistry Orthopaedics Ophthalmologist Others, please specify _______________

Do you have any health insurance? If Yes,

Yes

No

Name of Insurance Company ________________________________________________ Maximum Insurance Coverage Amount ________________________________________

PARADISE HEALTH CLIENT FORM (2013-page2)

PLEASE READ CAREFULLY: 1. The following persons are excluded from entry into the Philippines: a. Insane persons/person afflicted with a dangerous contagious disease, Persons with manifestation of any anxiety, depressive, psychotic, personality and psychological disorders identified and observed during the conduct of medical examination as well certifications of the persons attending the physician. b. Pauper, vagrant, and beggars, persons likely to become a public charge, stowaways, persons who have been excluded or deported from the Philippines including those deported as indigent aliens or persons not properly documented for admission; c. Persons who have been convicted of a crime involving moral turpitude, prostitutes or procures, persons coming for any immoral purposes; d. Persons who believe in or advocate the overthrow by force and violence of the Government of the Philippines, or of constituted lawful authority, or who disbelieve in or are opposed to organized government; people who use force and violence in pursuit of their advocacies; e. Persons over fifteen (15) years of age, physically capable of reading, who cannot read printed matter in ordinary use in any language selected by the alien, persons who are members of a family accompanying an excluded alien; or f. Persons coming to perform unskilled manual labour in pursuance of a promise or offer of employment; 2. Honouring of the applicants health insurance by the physician is not guaranteed. 3. The participation of Paradise Health Consultancy is limited only to the giving of assistance to the applicant. 4. The applicant can only avail of the services of Paradise Health Consultancy upon full payment of the service charge. 5. The service charge due to Paradise Health Consultancy is non-refundable. By affixing my signature here, I hereby certify I have understood all the terms and conditions presented above and that the information written are true and correct and any misrepresentation on my part will be grounds to disapproval of the application. (For Paradise Health Consultancy Use Only) Receiving Personnel:

_________________________________________________ Signature over Printed Name/Date

Date Signed:

--------------------------------------------------------------------------------------------------------------------------------------------------Proof of Application Date of Application: __________________________ Documents Submitted: _______________________________________________________________________________________ _____________________________________________________________________________________ Comments/Remarks: _________________________________________________________________________________________ ________________________________________________________________________________________