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Dental and Medicines with the Blue Cross

 

Individual health and dental insurance proposal!

Submit the proposal, receive the electronic signature form in your mailbox, and open your file.

Health declaration

Have the persons to be insured ever consulted, been treated, presented symptoms or been diagnosed for any of the following conditions? Answer: Yes or No!

Your banking information

Necessary to purchase your dental insurance

  • Blue Cross Dental and Medicines
  • Without the medical examination
  • Specimen check

Personal information - Blue Cross Dental and Medicines

gender

Civil status

Are you a smoker?

Weight change since last year. If yes, weight gained or lost

Disease

Cardiovascular/cerebrovascular system: hypertension, high cholesterol, arrhythmia, heart attack, angina, transient ischemic attack or stroke or neurological or any other heart or circulatory disorder?

Respiratory system: asthma, chronic bronchitis, emphysema, cystic fibrosis, sleep apnea, chronic obstructive pulmonary disease (COPD) or any other respiratory disorder?

Digestive system: ulcerative colitis, Crohn's disease, hepatitis, chronic pancreatitis, polyps or any other disorder of the stomach, pancreas, liver or intestinal system?

Genitourinary system: sugar or blood in the urine, kidney stones, problems with the kidneys, bladder, prostate or reproductive organs (such as infertility) or any sexually transmitted infections?

Neurological system: Parkinson's disease, multiple sclerosis, chronic headaches, dizziness, loss of consciousness, vertigo, epilepsy, paralysis or any other condition affecting the brain or spinal cord?

Endocrine system: diabetes, anemia, thyroid disorder, any other form of endocrine or glandular disease?

Musculoskeletal system: any condition of the muscles, bones, ligaments or cartilage such as arthritis, abnormalities of the neck, back (including mid and lower back pain), spinal column such as scoliosis or dystrophy?

Immune system: immune system deficiency, acquired immunodeficiency syndrome (AIDS) or HIV positive, systemic lupus erythematosus, Huntington's disease or any hereditary disease?

Nervous system: Schizophrenia, bipolar disorder, personality disorder, depression, anxiety, burnout, anorexia, attention deficit disorder with or without hyperactivity (ADHD), sleep disorder (including insomnia) or any other disorder mental or nervous?

Other conditions: Fibromyalgia or chronic fatigue syndrome, tumor (benign or malignant), leukemia or any other blood disease, skin disorder (including acne) or any form of malignancy, breast abnormality or abnormal mammogram ?

Over the past two years, have the persons to be insured: a) had to consult and/or receive treatment from a specialist or therapist (chiropractor, physiotherapist, psychologist, massage therapist, etc.) or have they been advised to do so? If yes, please indicate the annual frequency and reason. b) purchased or planned to purchase orthopedic shoes, supplies or podiatric orthotics? c) purchased or rented the following medical accessories or devices, or planned to do so: artificial limbs, orthopedic devices, walker, wheelchair, oxygen compressor, continuous positive airway pressure (CPAP) breathing apparatus, ostomy accessories , etc.?

ADDITIONAL HEALTH STATEMENT RELATED TO CORONAVIRUS (COVID-19)

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