Patient Registration
National Hospital
Personal Information
Full Name
*
Email Address
*
Mobile Number
*
Date of Birth
*
Gender
*
Select Gender
Male
Female
Other
Blood Group
Select Blood Group
A+
A-
B+
B-
O+
O-
AB+
AB-
Marital Status
Select Marital Status
Single
Married
Other
Aadhaar/PAN/Other ID Number
For identity verification (optional)
Address Information
Address Line 1
*
Address Line 2
City
*
State
*
PIN Code
*
Country
*
Emergency Contact
Contact Person Name
*
Relationship
*
Emergency Number
*
Medical History (Optional)
Allergies
Chronic Diseases
Past Surgeries
Current Medications
File Uploads (Optional)
Profile Photo
Choose File
JPEG/PNG format, max 2MB
ID Proof
Choose File
PDF/JPG/PNG format, max 5MB
Medical Reports
Choose File
PDF/JPG/PNG format, max 10MB
Account Information
Password
*
Confirm Password
*
Security Verification
Captcha
*
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and
Privacy Policy
Note:
A unique patient ID will be automatically generated upon successful registration.
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