PATIENT REGISTRATION DETAILS

Title *First Name *Middle NameLast Name *

Gender *Marital Status *Phone Number *Additional Phone Number

Email *City *StateCountry

Pin code *ID Proof Name *ID No *SMS

AddressEmergency Contact name *Emergency Contact Phone no. *

Nationality *Date of Birth *Religion

Passport No. Passport Issue Date Passport Expiry Date

Next of Kin Name *Next of Kin Phone No. *Next of Kin relationship *Payment type