PATIENT REGISTRATION FORM | EZY Healthcare

Australian Company Number 666 477 505

PATIENT REGISTRATION

Patient Registration

Update of Information

Patient's Particulars

Name

NRIC No/Passport No

Sex:

Male

Female

Date of Birth

Marital Status

Race

Nationality

Occupation

Resident Status

HEALTH TOURIST ( TOURIST COME FOR THE PURPOSE OF MEDICAL TREATMENT )

TOURIST ( TOURIST WHO FALL SICK DURING HOLIDAY )

Address

Postcode

City/Town

State

Country

Mobile No.

Referred By :

Referral Contact Number :

Person to Contact During Emergency

Name

NRIC No/Passport No

Relationship

Address

Postcode

City/Town

State

Country

Phone (H)

Phone (O)

Mobile

Patient Medical Report Detail

I hereby confirm that all particulars provided are true and Ezyhealthcare reserves the right to seek further clarification before processing my request.

Warranty Clause I also hereby warrant that I have obtained all necessary consent from the third party where I have provided their personal information as part of my registration.

PATIENT REGISTRATION

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PATIENT REGISTRATION

Online Consultation (Telecare)

Online Consultation (Telecare)