Medical Declaration Form – Heritage Health

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Welcome to the Heritage Health medical history questionnaire.

Assessing your medical background enables us to propose policies with improved terms.

Consent(Required)

The process involves answering questions that are designed to capture the information we need to build a clear and accurate picture of you and your dependant’s health.

As the applicant you have to complete this form on behalf of all people to be insured. If you are unsure about anything on this questionnaire, please contact Heritage Health immediately on 0800 131 0764

I understand(Required)

Duty of disclosure

Duty of disclosure(Required)

It is important you take reasonable care to complete all of the health questions honestly and fully for any person to be covered by the plan because we will use the answers you give to determine what medical conditions your policy will cover.

If you do not take reasonable care and the information provided by you is inaccurate or incomplete, this may result in a claim not being paid, your underwriting terms being changed, your cover being cancelled, and/or any treatment costs already paid, being reclaimed.

I understand(Required)

Your Personal Information

Please tell us who the policyholder will be for this Private Medical Insurance plan

Your Name(Required)

First Last

Medical History – Cancer

In the last 5 year's has the policyholder had any form of cancer ?(Required)

Yes

When were you diagnosed with Cancer?(Required)

DD slash MM slash YYYY

What treatment did you receive for your Cancer ?(Required)

Please let us know what Cancer you were diagnosed with ?(Required)

Medical History – Cancer

Please select the option which best describes you current medical state in relation to Cancer ?(Required)

I am waiting for Surgery

I have had treatment and I’m being monitored under the care of my Consultant

I have had treatment and I have been discharged from the care of my Consultant. I only see my GP

I have been discharged, I have no symptoms. I no longer have Cancer

Medical History – Hearth or Circulatory

In the last 5 years, have you had any type of Heart or Circulatory condition?(Required)

Yes

When were you diagnosed with Heart or Circulatory issue?(Required)

DD slash MM slash YYYY

Please select the option which best describes you current medical state in relation to Heart or Circulatory issue?(Required)

I am waiting for Surgery

I have had treatment and I’m being monitored under the care of my Consultant

I have had treatment and I have been discharged from the care of my Consultant. I only see my GP

I have been discharged, I have no symptoms. I no longer have this issue.

Medical History – Arthritis

In the last 5 years, have you had any form of Arthritic condition?(Required)

Yes

When were you diagnosed with Arthritic issue?(Required)

DD slash MM slash YYYY

Please select the option which best describes you current medical state in relation to Arthritic issue?(Required)

I am waiting for Surgery

I have had treatment and I’m being monitored under the care of my Consultant

I have had treatment and I have been discharged from the care of my Consultant. I only see my GP

I have been discharged, I have no symptoms. I no longer have this issue.

Medical History – Undiagnosed

Do you have any planned or pending investigations, treatment or surgery for any condition (this applies whether the treatment is planned privately or under the NHS)?(Required)

Yes

When were you diagnosed with this issue?(Required)

DD slash MM slash YYYY

Please select the option which best describes you current medical state in relation to this issue?(Required)

I am waiting for Surgery

I have had treatment and I’m being monitored under the care of my Consultant

I have had treatment and I have been discharged from the care of my Consultant. I only see my GP

I have been discharged, I have no symptoms. I no longer have this issue.

How do we contact you

Your Email Address(Required)

Your Phone(Required)

Do you want to add another person (your family member or friend)?

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