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Registration Form

Registration Form – ETHOS HEALTH CARE

(Privacy Assured)

Please fill the form and submit it to us. Please make sure that all the details are filled correctly. We assure you that all the details provided by you are completely private and we never disclose / share / sell this information to any third party. In case you wish to remain anonymous, you may do so. In such case you may use special registration number for communication.

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Fields marked with an * are essential for online account registration.

General Information:

First Name: _______________________________ Middle Name:________________________

Last Name: ______________________________   Gender:  Male / Female / Other_________

Address: ___________________________________________________________________________

City: _______________________________ State: ________________ PIN / Zip: __________

Country: _______________________Phone: ________________________________________

Mobile:____________________________________

Emergency Contact Person______________________________  Relation__________________

Emergency Contact No: __________________________________________________________

Account Log In: Email address and password for account access

*E-Mail Address: ___________________________________________

*Password: ________________________________________________

Health History

Current Complaints

___________________________________________________________________

___________________________________________________________________

Medical History

____________________________________________________________________

_____________________________________________________________________

Surgery History

_____________________________________________________________________

Allergy History

_____________________________________________________________________

Family History

______________________________________________________________________

Substance Abuse

______________________________________________________________________

Investigations

______________________________________________________________________

Or attach copy

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