New Patient Registration
Please fill in the information completely, correctly and truthfully for the benefit of providing appropriate medical services. The information you provide will be used for the purpose of registering for service only and will be kept safely according to the hospital's standards.
Title
First Name
Last Name
Birthday
Nationality
Marital Status
Occupation
Mobile Phone
Current Address
E-Mail
Please enter a valid email address.
History of drug/food allergies
Persons authorized by the hospital to be contacted in case of emergency and should be a family member.
Name-Surname
Relationship
Telephone
Name-Surname
Relationship
Telephone
Name-Surname
Relationship
Telephone
Persons authorized to access medical data
Name-Surname
Relationship
Telephone
Name-Surname
Relationship
Telephone
Name-Surname
Relationship
Telephone
Contact person in case the patient cannot be contacted
Name-Surname
Relationship
Telephone
Name-Surname
Relationship
Telephone
Name-Surname
Relationship
Telephone