Patient Registration Form
Patient Information
Salutation*
Mr.
Mrs.
Ms.
First Name*
Middle Name*
Last Name*
Gender *
Male
Female
Other
Date of Birth*
Nationality*
Please select your nation
India
UAE
USA
Contact Number*
Email*
ID Proof*
Select proof
Emirates ID
Passport
Emirates ID*
Choose file
Passport Number*
Choose file
Address - Residence
Building/Floor/Flat*
Street Name*
City/Emirate*
P.O. Box*
Country*
Please select your country
India
UAE
USA
Insurance Provider Information
Provider Name
Please select provider name
Provider Name 1
Provider Name 2
Provider Name 3
Insurance ID/No.
Valid till
Emergency Contact 1
Name*
Relation*
Mobile number*
Emergency Contact 2
Name
Relation
Mobile number
Pre-existing condition
Diabetes
High/Low blood Pressure
Epilepsy
Asthma
Others
Consent
Provided information is to the best of my knowledge. I authorize etisalat to use this information to add given details and register me as a patient. Any error in information will not be used to hold etisalat liable in any circumstances.
