Hanoville Specialist Hospital & Fertility Center
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Patient Registration
Complete this form to register as a patient at Hanoville Hospital
Full Name*
Date of Birth*
Gender*
Select Gender
Male
Female
Other
Address*
Phone Number*
Email
Blood Type
Select Blood Type
A+
A-
B+
B-
AB+
AB-
O+
O-
Medical History (Existing Conditions, Allergies, etc.)
Service Needed*
Select Service
General Consultation
Surgical Procedure
Maternity Services
Pediatrics
Emergency Care
Other
Type of Surgery
Maternity Details
Select Option
Prenatal Care
Delivery (Natural Birth)
Delivery (C-Section)
Postnatal Care
Preferred Appointment Date
Do you have medical insurance?
Yes
No
Insurance Provider
Policy Number
I consent to Hanoville Hospital collecting and processing my personal data for medical purposes.*
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