LIAISON CHRONIC DISEASE MANAGEMENT ENROLLMENT FORM

Liaison Group Wellness and Health Management program involves managing clients with long term health conditions, thereby allowing patients to enjoy life.
These include but not limited to Hypertension, Diabetes, Cancers, Asthma, HIV/AIDS, Cardiac Conditions, Arthritis, Epilepsy among others.
Liaison Group has partnered with various providers to ensure that registered wellness members enjoy: Cost effectiveness i.e. negotiated provider rate; Reduction of admissions; Reduction of disease progression among others.
To Enrol to this programme please fill in the below.

Contacts

Call :0703 071 111/222

Email address :wellness@liaisongroup.net

Name

First

Middle

Last

Employer

Membership Number

Age

Email Address

Mobile Number

Scheme/ Company

Doctors Name & Hospital Name

If Other is checked write your condition here. Write None if it is not applicable

Next of Kin

Phone Number - Next of Kin

Comments

Note

Liaison Group and the hospital/doctor (s) will handle my medical information with due diligence and utmost confidentiality.

Chose your preferred Doctor/Hospital

AAR HEALTHCARE

LUTON

HEALTHBASICS INTERNATIONAL