UHID Pre-Registration - Asiri Health

UHID Pre-Registration

Title *

Initials:*

First name:*

Last name:*

Date of birth:*

Age *

Gender *

Male Female

Civil Status *

Single Married

Mobile phone:*

Land phone:

Email:*

NIC/Passport:*

Height (cm):

Weight (kg):

Guardian

Guardian name:*

Guardian NIC:*

If age is under 18 years, the Guardian's information must be entered.