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Client Details
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A - INSURED PERSON DETAILS
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B-PLAN SELECTION
FOUNDATION STANDARD – VND 500,000,000 EXECUTIVE – VND 1,000,000,000 PREMIER – VND 2,000,000,000
In-patient
Out-patient
Additional Benefit
Master
Additional Benefit
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Discount Options
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Payment option:
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C-QUESTIONNAIRE
1. - Are you currently covered by a medical policy? (if YES, please provide a copy of the policy and benefit schedule)
  - Have you had any medical insurance application or policy declined, rated, restricted, or cancelled, at any time in the past? If YES, please state the reason:
2. Have you ever had symptoms of or been diagnosed with, investigated or treated for any of the following:
2.1. Psychological or psychiatric conditions, drug and alcohol issues or sleep disorders? Ex: depression, anxiety, stress, autism, insomnia, sleep apnea, drugs and alcohol dependency, etc.
2.2. Heart or circulatory conditions? Ex: high/low blood pressure, angina/chest pains, heart attacks or heart failure, coronary arteries, ischemia, deep veins thrombosis, varicose vein, etc.
2.3. Tumors, growths or cancer? Ex: polyps, benign growths or cysts, lymphomas, any cancers or pre-cancerous conditions, etc.
2.4. Brain or nervous system conditions? Ex: stroke/transient ischemic attack (TIA), syncope, seizure or epilepsy, migraines, multiple sclerosis, meningitis, neuritis, etc.
2.5. Diabetes, thyroid, metabolic or any other endocrine disorders? Ex: diabetes type 1 or type 2, hypothyroidism or hyperthyroidism, dyslipidemia, pituitary or adrenal problems, etc.
3. In the last 5 years, have you seen a physician, or experienced any symptoms, or been admitted to a hospital, or medical facility for an operation or procedure, or undergone any tests or investigations, for any of the following conditions?
3.1. Eyes, ears, nose or throat? Ex: glaucoma, cataracts, retinal detachment, macular degeneration, hearing difficulties/loss, relapsed otitis, tonsillitis, sinusitis, etc.
3.2. Breathing or respiratory conditions? Ex: asthma, chronic obstructive pulmonary disease (COPD), emphysema, shortness of breath, pneumonia, bronchitis, tuberculosis (TB), all kind of respiratory allergies, etc.
3.3. Urinary, kidney, ureter, bladder, urethral or prostate conditions or STI? Ex: kidney, bladder, urethra infections or stones, prostate problems, sexually transmitted infections, etc.
3.4. Stomach, liver, gall-bladder, pancreas, or digestive system conditions? Ex: gastritis, gastroesophageal reflux disease (GERD), hepatitis, cirrhosis, gallstones, pancreatitis, irritable bowels, colitis, hemorrhoids/piles, persistent diarrhea, Crohn’s disease, digestive ulcers, abdominal pain, bleeding, all kind of hernia, etc.
3.5. Neck, back, joint, muscular or skeletal problems? Ex: neck, back or joint pain, sciatica, arthritis, osteoarthritis of spine, gout, joint replacements, fracture, cartilage or ligament problems, etc.
3.6. Auto-immune disorders? Ex: HIV/AIDS, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, etc.
3.7. Skin conditions? Ex: eczema, dermatitis, rashes, psoriasis, acne, moles that itch or bleed, or all kind of skin allergic reactions, etc.
3.8. Gynecological or breast conditions? Ex: irregular periods, fibroids, prolapse, endometriosis, abnormal Pap test, cervix, uterus, ovaries or fallopian tube disorders, etc.
3.9. Any physical defect or congenital condition?
4.Have you been advised to undergo or have you undergone any medical test, medical check-up, taken medication, or had a procedure not mentioned above?
D-SUPPLEMENT
E-DECLARATION
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