SV CARE

APPLICATION FORM

COMPANY DETAILS
Company Name
No. of Employees
Contact Name
Designation
Mobile Number	(10 digit number)
Email ID
Company Address
City	(max 30 characters a-z and A-Z)
Postal Code	(6 digit number)
State	(max 30 characters a-z and A-Z)
Country
FACILITIES CHARGEABLE
Normal Medical Treatment	Yes No
Minor Surgery	Yes No
Essential laboratory/ urine tests	Yes No
Chest X-ray	Yes No
Ultrasound /ECG	Yes No
Vaccination/Immunization	Yes No
Pre-employment Medical Exam	Yes No
EMPLOYEE / PATIENT IDENTIFICATION (tick one only)
Name list provided (please inform clinic promptly of any updates)
Company Authorization Slips /Books / Cards
Clinic Attendance Chit /Slip
Staff Tag / Company ID card
ELIGIBILITY OF MEDICAL COVERAGE
Company Employees only	Yes No
Family members covered	Yes No
Family of All Employees	Yes No
Family of Management only	Yes No
Including children’s vaccination under Ministry of Health’s guidelines	Yes No
Including pregnancy (antenatal/postnatal) care	Yes No