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Review Your Details

First Name

Family Name

Emirate

Mobile Number

Email Address

Date of Birth

Gender

Coverage for

Is your monthly salary below AED 4001?

Chronic Conditions

Do you have any pre-existing condition/ have been diagnosed and / or treated for any Chronic condition? If yes, please select

Yes No

Critical Conditions

Have you ever been diagnosed and/or treated for any Critical cases? If yes, please select

Yes No

Pregnancy

Are you currently pregnant?

Yes No

Last Menstrual period date

If Yes, have there been any complications to date?

Are you currently trying to get pregnant?

Yes No

Are you undergoing any form of fertility treatment?

Yes No

Member Type

Applicant UID

Emirates ID

Sponsor UID

Passport No.

Country

Residence Location

Visa File No.

Marital Status

Relation With Sponsor

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