Membership Amendment Thank you for connecting with us. We will respond to you shortly. 11https://cellmed.co.zw/wp-content/plugins/nex-formsfalsemessagehttps://cellmed.co.zw/wp-admin/admin-ajax.phphttps://cellmed.co.zw/membership-amendmentyes1fadeInfadeOut ENTER MEMBERSHIP DETAILS BELOWName of Employer / Account HolderAuthorised Signatory*Member's Name*Membership Number*Commencement Date*Email AddressMobile Number *Please enter number we can use to contact you Back Next Enter details to Amend / Terminate / Add Membership belowNAMEDOBRELATIONSHIPID NUMBERACTION*Name 1*DOB 1*R-Ship 1ChildFatherMotherSisterBrotherGrandmotherGrandfatherID Number 1*Action 1AddAmendTerminateName 2DOB 2R-Ship 2ChildFatherMotherSisterBrotherGrandmotherGrandfatherID Number 2Action 3AddAmendTerminateName 3DOB 3R-Ship 3ChildFatherMotherSisterBrotherGrandmotherGrandfatherID Number 3Action 3AddAmendTerminate*Reasons for changesChange Package?NoYesCurrent PackageUniversal PlusUniversal LiteSupremeSuperiorVitalEssentialBaseManuka (Diaspora)Lavender (Diaspora)Clover (Diaspora)New PackageUniversal PlusUniversal LiteSupremeSuperiorVitalEssentialBaseManuka (Diaspora)Lavender (Diaspora)Clover (Diaspora)Medical HistoryName of member / beneficiary ConditionDoctor's NameTreatment AdministeredDoctor's Telephone Back Next ConsentI declare that the information provided is correctDateSignature Back Submit
