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Hello,
Patient Registration
Note :
Please fill the information
as per your Aadhaar card
details, To create your account as patient,
age should be greater than or equal to 18 years.
Personal Details
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Age
*
Gender
*
Select
Male
Female
Other
Marital Status
*
Select
Single
Married
Widowed
Divorced
Blood Group
Select
A +ve
A -ve
B +ve
B -ve
O +ve
O -ve
AB +ve
AB -ve
Insurance Provider
Contact Details
Address
*
Country
*
Select
India
State
*
Select
City / District
*
Select
Zip Code
*
Mobile Number
*
Alternate Mobile Number
Emergency Mobile Number
*
Email ID
*
Identification Details
Govt ID Type
*
Select
Aadhaar Card
Govt ID Number
*
Upload ID Proof
*
( Note: Please upload .pdf file less than 100KB. )
( Note: Select None or options as applicable. )
Family Medical History
None
Heart Attack
Diabetes
Dwarfism
Cretinism
Kidney Disease
Blood Disorders
Lung Disease
High Blood Pressure
Asthma
High Cholestrol
Cancer
Stroke
Genetic Birth Disorder
Dementia
Alzeihmers
Anemia
Heart Defect
Spinal Defect
Liver Disorders
Self Medical History
None
Heart Attack
Diabetes
Dwarfism
Cretinism
Kidney Disease
Blood Disorders
Lung Disease
High Blood Pressure
Asthma
High Cholestrol
Cancer
Stroke
Genetic Birth Disorder
Dementia
Alzeihmers
Anemia
Heart Defect
Spinal Defect
Liver Disorders
Surgeries
Allergies
Drug History
None
Opiods
Cocaine
Heroin
LSD
PCP
Marijuana
Long Standing Medication
Social History
None
Alcohol
Smoking
Chewing Tobacco
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