Patient Registration

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Id

*

Full Name

*

Date of Birth

*

Gender

Aadhaar Number

*

Ayushman Card Number

*

Contact Number

*

Email Address

**

Address

*

City

*

State/Region

*

Country

*

Postal Code

*

Emergency Contact Name

*

Emergency Contact Number

*

Medical History

*

Allergies

*

Current Medications

*

Primary Insurance Provider

*

Insurance Policy Number

*

Registration Date

*

Status

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