Patient Enrolment

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Patient Enrolment Page 1 of 3

Email^*

Password^*

Password must be at least 7 characters long.

Re-Enter Password^*

Password must be at least 7 characters long.

Prefix:^*

Patient First Name:^*

Patient Middle Name:

Patient Last Name:^*

Patient Gender:^*

Male
Female
Other

Patient DOB:^*

Patient Marital Status:^*

Married
Not Married

WhatsApp Number:^*

Agree to send WhatsApp Messages:

Any other number:

Nationality:^*

Preferred Language:^*

Page 2

Country:

City^*

Caregiver/Emergency Contact Details:

Current Treating Hospital:^*

Current Treating Doctor:^*

Current Treating Country:^*

Type of Cancer:^*

Page 3

Does your Medical Condition Allow you to travel:

Are you interested in getting Treated in your own Country from Art of Healing Cancer:

Would you need Air Ambulance:

Do you need a Visa to travel to India:

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