MEMBER REGISTRATION
Personal Information
*Coverage Class
*Title
*Last Name
*First Name
Other Name
*Date of Birth
*Gender
*Marital Status
Contact Information
*Mobile Phone
*Home Address
*E-Mail
*State of Residence
*LGA
*Pre-existing
Primary Provider Information
*Provider
Provider's Address
Data Consent
By submitting this registration form, I hereby consent to the collection, processing, and use of my personal data by PHILLIPS HMO. I understand and agree that my personal data may be used in accordance with the Data Protection Policy of PHILLIPS HMO.
