Mediplan Healthcare Limited: Tiship

STUDENT ID CARD NO *
MATRICULATION NO *
NAME OF INSTITUTION *
LASTNAME *
FIRSTNAME *
MIDDLENAME
GENDER
BLOOD GROUP *
ANY KNOWN ALLERGIES (Please mention)
DOB
CITY *
STATE *
MOBILE *
HOMEPHONE
EMAIL ADDRESS *
FACULTY (Please Note UNILAG students- that presently only Environmental Sciences, DLI and all Foundation students are being registered by Mediplan Healthcare Limited.) *
DEPARTMENT *
COURSE OF STUDY *
DURATION *
LEVEL *
PRIMARY HEALTHCARE PROVIDER *
UPLOAD PASSORT PHOTO (The file size should be smaller that 2MB and the photo size should be smaller than 3072 x 2304. The system processes only .jpg or .jpeg files) *
PROOF OF PAYMENT (Receipt)
BY CLICKING THE “SUBMIT” BUTTON AT THE END OF THE FORM YOU ARE CREATING AN ELECTRONIC SIGNATURE. THE SUBMISSION OF AN APPLICATION CONTAINING ANY FALSE OR MISLEADING STATEMENTS MAY RESULT IN DENIAL OF YOUR MEDICAL COVER.
I AGREE TO THE ABOVE TERMS