Medanta Patient Registration

Demographics

Title

Given Name *

Family Name *

Gender

Date of Birth

Marital Status

Father's / Husband's Name

Nationality

Religion

Education

Occupation

Identification

UHID (New)

Existing UHID (if registered before)

Aadhaar No.

PAN No.

Driving Licence No.

Residential Address

Address Line

City / Town / Village

District

State

PIN Code

Contact Information

Tel No. (Residence)

Tel No. (Office)

Mobile

E-mail ID

Language of Communication

Hindi English Other

Emergency Contact

Person to be notified in case of emergency

Relationship with patient

Contact No.

Address

For Foreign Patients

Passport No.

Passport Validity

Visa No.

Visa Validity

Country

Clinical & Referral

Allergies (if any)

Name of doctor to be consulted

Name and city/town of the referring doctor

Declaration / Consent

By signing this registration form, I, the undersigned hereby agree and consent:

That Medanta - Gurugram, its physician and medical personnel are authorized to administer and perform medical examination, investigations, medical treatment, procedures, blood transfusions, vaccinations and immunizations to the patient during the course of the patient care.
To the collection, processing, storage and use of patient's personal and clinical information for the purpose of providing medical treatment, educational and research purposes, insurance claim and billing purposes.
To be contacted by the hospital via phone, SMS, WhatsApp, mail or any other available means of communication, for patient's appointments, reminders, follow-up care.
To adhere to the prevailing billing policy of Medanta - Gurugram.
That any dispute shall be governed by the laws of India and subject to the exclusive jurisdiction of the court/forums at New Delhi/Gurugram (India).

Name of patient / attendant

Relationship with patient

Medanta — Patient Registration