Family Application Form Emergency Medical Rescue Membership Package Application Form Step 1 of 3 33% Personal DetailsClient Type Family Number of dependants12345678910More than 10Principal member name First Last ID numberNational ID/ Passport/Drivers' Licence Date of birth DD slash MM slash YYYY Weight (kgs)Mobile numberEmail Address Street Address Address Line 2 City Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Principal member medical historyHave you ever suffered from a heart condition? Yes No Have you ever been in hospital in the last year? Yes No Have you ever been diagnosed with: Diabetes HIV/AIDS Hypertension Epilepsy None of the above Allergies and pre-existing conditionsIndicate any allergies and pre-existing conditions you might have. Type Non if nothing Medical history details; for pre-existing conditions, chronic illnesses and or allergies.Please share any relevant medical history details we would need to know before assisting you in an emergency.Dependant 1 detailsFile uploadUpload dependant details in an Excel file showing names, ID number, age, gender, medical history and allergies.Max. file size: 2 GB.RelationshipHusbandWifeSonDaughterBrotherSisterFriendOtherDependant 1 name First Last Dependant 2 detailsRelationshipHusbandWifeSonDaughterBrotherSisterFriendOtherDependant 2 name First Last Dependant 3 detailsRelationshipHusbandWifeSonDaughterBrotherSisterFriendOtherDependant 3 name First Last Dependant 4 detailsRelationshipHusbandWifeSonDaughterBrotherSisterFriendOtherDependant 4 name First Last Select service and durationService Type ACE Plus Zambezi Cover(Locals) Zambezi Cover(Tourist) Tourist Cover (per 7 days) DurationSelect subscription duration. Minimum 6 months. 1 to 5 are for Zambezi Cover - Tourist Zambezi Cover - 1 dayZambezi Cover - 2 daysZambezi Cover - 3 daysZambezi Cover - 4 daysZambezi Cover - 5 daysZambezi Cover - 6 daysZambezi Cover - 7 daysTourist Cover - 7 daysTourist Cover - 14 daysACE Plus - 6 MonthsACE Plus - 12 MonthsACE Plus - 18 MonthsPayment detailsSubtotal Total per individual Payment Method Credit Card PayPal Drop in (Cash Payment) ConsentIntroduction: Welcome to ACE Air and Ambulance (Pvt) Ltd, your trusted partner in healthcare services. Before you proceed with the registration for our Electronic Medical Records (EMR) service, please take a moment to read and understand the following consent document. Consent to Electronic Medical Records (EMR) Service: By submitting this registration form, you are providing your explicit consent to ACE Air and Ambulance (Pvt) Ltd to collect, store, and manage your electronic medical records for the purpose of facilitating and improving healthcare services. This includes but is not limited to personal information, medical history, diagnostic reports, treatment plans, and any other relevant health information. Data Security and Confidentiality: ACE Air and Ambulance (Pvt) Ltd is committed to ensuring the security and confidentiality of your electronic medical records. We implement industry-standard security measures to protect your data from unauthorized access, disclosure, alteration, and destruction. Purpose of Data Collection: The primary purpose of collecting and maintaining your electronic medical records is to enhance the efficiency and quality of healthcare services provided by ACE Air and Ambulance (Pvt) Ltd. Your information may be used for medical diagnosis, treatment planning, billing, quality assurance, and research purposes, always adhering to applicable laws and regulations. Sharing of Information: Your electronic medical records may be shared with authorized healthcare professionals and organizations involved in your care, including but not limited to physicians, nurses, emergency medical personnel, and other relevant healthcare providers. ACE Air and Ambulance (Pvt) Ltd will not disclose your information to third parties without your explicit consent, except as required by law. Access and Control: You have the right to access, review, and update your electronic medical records. If you wish to make any changes or request the removal of specific information, please contact ACE Air and Ambulance (Pvt) Ltd through the provided channels. Withdrawal of Consent: You have the right to withdraw your consent for the use and storage of your electronic medical records at any time. However, withdrawal may impact the quality and continuity of healthcare services provided by ACE Air and Ambulance (Pvt) Ltd. Questions and Contact Information: If you have any questions or concerns about this consent document or the use of your electronic medical records, please contact our Privacy Officer at privacy@ace-ambulance.co.zw I have read, understood, and consent to the terms outlined in this document: I agree to the ACE Air and Ambulance (Pvt) Ltd Electronic Medical Records (EMR) Service Registration Consent. Δ
