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Capitalpro

“Caring for Your Health, After 60 – With Dignity, Comfort, and Trust.”

About Us

Registration Form

Please fill in all the required fields to avoid delays in your registration.

Registration Form

SECTION A: Personal Information

First Name

National ID Number

Last Name

Gender

Date of Birth

Marital Status

Address including post code/zip/city /province

SECTION B: Contact Details

Phone

Email Address

WhatsApp number if different

Preferred Method of Contact:

SECTION C: Emergency Contact

Next of Kin Full Name

Relationaship

Phone

SECTION D: Medical Information

Do you have any of the following conditions? (Tick all that apply)

Do you have difficulty walking or moving around?

Are you currently on medication?

Would you need home visits or mobile care?

SECTION E: Family / Guardian Details (if registering on behalf of someone)

Full Name, Your Relationship to Client, Your Phone Number

SECTION F: Plan Interest (Optional)

Which plan are you most interested in? (You can decide later)

Silver Plan – Basic medical care

Gold Plan – Extra support + home visits

Platinum Plan – Full cover + medication delivery

Not sure yet

SECTION G: Consent & Declaration

Declaration Required

I confirm that the information above is true to the best of my knowledge.

I understand that services will start in 2026, and this form is for pre-registration purposes only.

I agree to be contacted about health plans, pricing, and launch updates.

Thank You
We appreciate your interest. Once we’re ready to launch in 2026, our team will contact you with next steps, plan details, and how to begin your care journey.
📞 Contact us anytime: +447312726093 WhatsApp
📧 Email: info@capitalproagency.com
🌐 Website: www.capitalproagency.com/healthservice
💬 WhatsApp: +447312726093 WhatsApp

08001075155
07312726093

Capitalpro

“Caring for Your Health, After 60 – With Dignity, Comfort, and Trust.”

Registration Form

Registration Form

SECTION A: Personal Information

SECTION B: Contact Details

SECTION C: Emergency Contact

SECTION D: Medical Information

Do you have any of the following conditions? (Tick all that apply)

SECTION E: Family / Guardian Details (if registering on behalf of someone)

SECTION F: Plan Interest (Optional)

SECTION G: Consent & Declaration

Thanks for submitting!