Patient Registration

Identification Details

Exactly as per identity proof

Initial / Title*

First Name*

Middle Name

Last Name*

Personal Information

DOB*

Age at Registration

Gender*

Marital Status

Father Name

Spouse's Name

Education*

Occupation

Family Income Monthly(Rs.)

Nationality*

Religion*

Mother Tongue*

Identity Proof

Nominee Name*

Exactly as per identity proof

Relationship with Nominee*

Nominee Identity Proof

Upload Nominee Identity Proof

.jpg,.pdf,.png,.jpeg (File size should be between 5kb and 200kb)

Referral Information

Referred For

Referred By Doctor/Hospital Clinic

Address of Referring Doctor/Hospital Clinic

Choice of Doctor (at ACTREC), if any

Permanent Address

Address*

Country*

State*

District*

Other District

City/Town/Village

Pincode

Telephone No.

Mobile No.(For all communication)*

Alternative Mobile No.

Email Id

Re-confirm Email Id

Resident of Mumbai (More than 1 Year)

Address for Correspondence

Same as a Permanent Address

Address*

Country*

State*

District*

Other District

City/Town/Village

Pincode

Telephone No.

Mobile No.

Fax No.

Kin's Details

Same as a Permanent Address

Same as a Correspondence Address

Name*

Relationship with Patient*

Address

Country

State

District

Other District

City/Town/Village

Pincode

Telephone No.

Mobile No.

Fax No.

Email Id

Re-confirm Email Id

Medical Insurance

Do you have Medical Insurance

Yes No

Travel Concession (Near Permanent Residence)

Nearest Port for travel

From Date

To Date

Railway (Station)

Air (Airport)

Road (Terminus)

From

Identification Mark 1*

Identification Mark 2

Anticipated Date of Visit to ACTREC

Note*

If you are availing State/ Central Health Care Scheme, please submit the necessary documents at the centre for enrollment.
Please carry yopur Aadhar Card along with duly filled form.

Verification Code*

I understand and agree that the above filled information is true and correct to the best of my knowledge.*

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