Please complete the following information as fully in block letters.

1. How many weeks or months pregnant are you since you had a pregnancy test or a doctor or nurse said you were pregnant?

2. How many prenatal visits have you so far done during this pregnancy?
If No,
4. Did you have any of these problems during your last pregnancy? For each item, tick (Yes) if you had the problem or (No) if you did not
5. If you are currently experiencing any of the above, please tell us which. (Indicate a,b,..)

MEDICAL DECLARATION (for self and Spouse) Please indicate by ticking if you or your spouse, are suffering from / being treated for any of the following:
If the answer to any of the above is YES, please give details.

Case Medcare provides individual, family and group (corporate) health insurance plans. These plans are Client centred, Affordable, Safe and Effective in reducing the out of pocket payment burden that leads many households to financial catastrophe.