Corporate Subscription - ACE Air & Ambulance

Corporate Application Form

Emergency Medical Rescue Corporate Membership

Step 1 of 2

Primary Contact Details

Client type

Corporate

Company name

Number of additional members

Contact member

First Last

ID number

National ID/ Passport/Drivers' Licence

Primary contact number

Primary email

Company address

Street Address Address Line 2 City Country

File upload

Upload other member details in an Excel file showing names, ID number, age, gender, medical history and allergies.

Max. file size: 2 GB.

Corporate member 1 details

Corporate member 1 name

First Last

Corporate member 2 details

Corporate member 2 name

First Last

Corporate member 3 details

Corporate member 3 name

First Last

Corporate member 4 details

Corporate member 4 name

First Last

Select service and duration

Service type

EMR Advanced

Corporate Cover

Zambezi Cover (Locals)

Zambezi Cover (Tourist)

Duration

Select subscription duration. Minimum 6 months. 1 to 5 are for Zambezi Cover - Tourist only

Consent

Introduction:
Welcome to ACE Air and Ambulance (Pvt) Ltd, your trusted partner in healthcare services. Before you proceed with the registration for our Electronic Medical Records (EMR) service, please take a moment to read and understand the following consent document.

Consent to Electronic Medical Records (EMR) Service:

By submitting this registration form, you are providing your explicit consent to ACE Air and Ambulance (Pvt) Ltd to collect, store, and manage your electronic medical records for the purpose of facilitating and improving healthcare services. This includes but is not limited to personal information, medical history, diagnostic reports, treatment plans, and any other relevant health information.

Data Security and Confidentiality:

ACE Air and Ambulance (Pvt) Ltd is committed to ensuring the security and confidentiality of your electronic medical records. We implement industry-standard security measures to protect your data from unauthorized access, disclosure, alteration, and destruction.

Purpose of Data Collection:

The primary purpose of collecting and maintaining your electronic medical records is to enhance the efficiency and quality of healthcare services provided by ACE Air and Ambulance (Pvt) Ltd. Your information may be used for medical diagnosis, treatment planning, billing, quality assurance, and research purposes, always adhering to applicable laws and regulations.

Sharing of Information:

Your electronic medical records may be shared with authorized healthcare professionals and organizations involved in your care, including but not limited to physicians, nurses, emergency medical personnel, and other relevant healthcare providers. ACE Air and Ambulance (Pvt) Ltd will not disclose your information to third parties without your explicit consent, except as required by law.

Access and Control:

You have the right to access, review, and update your electronic medical records. If you wish to make any changes or request the removal of specific information, please contact ACE Air and Ambulance (Pvt) Ltd through the provided channels.

Withdrawal of Consent:

You have the right to withdraw your consent for the use and storage of your electronic medical records at any time. However, withdrawal may impact the quality and continuity of healthcare services provided by ACE Air and Ambulance (Pvt) Ltd.

Questions and Contact Information:

If you have any questions or concerns about this consent document or the use of your electronic medical records, please contact our Privacy Officer at privacy@ace-ambulance.co.zw

I have read, understood, and consent to the terms outlined in this document:

I agree to the ACE Air and Ambulance (Pvt) Ltd Electronic Medical Records (EMR) Service Registration Consent.