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Medical QuestionnaireArno Strauss2021-11-22T09:34:01+02:00

Medical Questionnaire


Sharing of Personal Information Declaration

By providing the information in this form you agree that Cinagi (Pty) Ltd and its underwriter, Infiniti Insurance Ltd may :

  • use this information to provide you with administrative and insurance services.
  • disclose this information to persons and entities that it is necessary to disclose this information to in order to provide you with the aforementioned services.
  • have the right to communicate with you electronically about any changes or general information relating administrative processes or changes to the Cinagi policy benefits and premiums.
  • only transfer your personal information outside South Africa if you have provided an email address that is hosted outside South Africa or to administer certain services, for example, cloud services and/or the Medical Second Opinion service.

You further agree that:

  • if submitting your dependents’ relevant personal information, you hereby confirm that you are duly authorised to share such information with us. We will furthermore process their information for the purposes and in the manner as set out in our Privacy Statement
  • I, as the applicant, have the necessary authority and knowledge to complete the medical questions and provide the warranties provided in the medical questionnaire section above on behalf of myself and all of the dependants covered on this policy (if applicable).
  • I have not withheld any information which may be material to the assessment of risk under this policy.

You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement and the contents thereof.

Consent(Required)
Name(Required)
Email(Required)
Question 1: In the past 12 months, have you or any dependant consulted/received advice from any medical specialist, and/or undergone any form of X-ray / CT-MRI-PET scan?(Required)
Question 2: Are you aware of any reason - including pregnancy/childbirth - that you or any dependant may be admitted to a hospital or a day clinic within the next 12 months(Required)
Question 3: Do you or any dependant currently: take any ongoing medication, and/or receive any other ongoing treatment for any medical condition?(Required)

Details for Question 1

Name and surname
Date of Treatment/Consultation(Required)
Name and surname
Date of Treatment/Consultation(Required)

Details for Question 2

Name and Surname

Details for Question 3

Name and Surname
Date of your last consultation*(Required)

ABOUT

At Cinagi, we are committed to excellence. Our many years of experience in the healthcare industry, combined with excellent service levels gives you the peace of mind that you have the best health insurance cover available.

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© Copyright 2019 -    |   All Rights Reserved   |   Cinagi is an authorised financial services provider (FSP 50104).
Underwritten by Infiniti Insurance Ltd, a licensed Non-Life Insurer and authorised financial services provider (FSP 35914)
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