Patient Registration

PATIENT’S PARTICULARS FOR REGISTRATION(To be filled in by the Patient/Attendant in Capital Letters)

Date : {{currentdatetime}}

*Prefix

Prefix Required Please select Prefix!

*Patient's Name(in Capitals Letters)

Name Required Name cannot be Number Name Required

*Sex

Gender Required select your Gender!

*Date of Birth

*Date of Birth

*Email

*Mobile No.

Mobile Number Required Mobile No Should be {{mobilelen}} digits Mobile Number Required!

Age

Guardian Relation

Father / Husband's Name

Mother's Name

Religion

Nationality

Marital Status

Patient's Occupation

Alternate Mobile No.

Mobile No Should be {{mobilelen}} digits

Parmanent Address :

Address 1

Address 2

State

City

Pin Code

Local Address :

Copy Parmanent Address

Address 1

Address 2

State

City

Pin Code

I hereby declare that the information furnished above is true, complete and correct to the best of my knowledge and as per government ID.