Registration Form

Please fill in the form below and ensure accurate information for submission.

*Mandatory field

Do you smoke? If yes, please input average daily use. If no, please input 'N/A'.

  1. Question No.
  2. Date of first occurrence of sign and symptom
  3. Disease/ medical condition / sign and symptom

    1. Treatment / Investigations / tests/ scan that have been performed
    2. Date of such treatment / investigation /tests/ scan
    3. Result of such investigations / tests / scan
  5. Present condition (such as whether fully recovered, follow up action / medication / next follow up date)
  6. Date of last follow-up medical consultation / treatment
  7. Name of doctor who treated the disease / sickness / medical condition / sign and symptom
  8. Name of Hospital, where applicable
  9. Provide copies of relevant investigative reports (if any) by sending email to staff.group.insurance.hkg@prudential.com.hk

If you have answered ‘NO’ to all of the questions above, please input ‘N/A’ in this part.

 

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