Medical registration form is used as the initial step by the organizations or patients to register their employees or an individual with some authenticated medical organization (hospital, nursing home & clinic).
Sample Medical registration form:
- Registration form Number: ___________
- Date of registration: ____/____/____
- General information of the patient or employee:
Name of the Patient: ___________________
Age: _________, Sex: ____________, Blood Group: __________
Contact number: ___________________________
E-mail Address: ___________________________
- Professional information:
Serving with: __________________
Organization Address: ___________________
Landline Number: __________________
Concerned e-mail id: ________________
- Medical information:
Mention the brief medical history of the patient/ employee: __________
What is the current status of the fitness: _____________________________?
Are you allergic to any medicines or injection: ___________________?
Mention if you are taking any treatment for any injury/ disease: ______________
Are you registered with some other medical organization as well: _____________?
- Singed by the patient/ employee: _____________
- Registered by: _______________