Patient Registration
: Patient details :
First name:
Last name:
Mobile No.:
Age:
Email:
Password:
Confirm Password:
DOB:
Select Patient Blood Group:
A+
A-
B+
B-
AB+
AB-
O+
O-
don't know
Gender :
Female
Male
other
Which hospital is the patient in :
City:
State:
Zip:
: Emergency Contact Information :
First name:
Last name:
Mobile No.:
Relation:
Email:
: Healthy & Unhealthy Habits :
Alcohol Consumption
I Don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Do You Smoke?
No
0-1 pack/day
1-2 pack/day
2+ pack/day