Rhythm Heart Self Registration

Self Registration

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First Name* Please Enter First Name

Middle Name

Last Name* Please Enter Last Name

Gender * Please Select Gender

Date of Birth (dd/mm/yyyy)* Please Select date of birth

Email Id Invalid email id format !

Mobile No * Please Enter Mobile No

Country * Please Select Country

State * Please Select State

City * Please Select City

PIN Code

Address 1 * Please Enter Address

Address 2

Identification (Aadhar) No

Emergency Contact Number

Relation to Patient

I, the undersigned, declare that the above information provided by me are true to the best of my knowledge and hereby provide my consent to the Rhythm Heart Institute to provide Medical Care, Treatment, Conduct Investigations and Diagnostic Procedures necessary for the above mentioned individual by Medical Staff at Rhythm Heart Institute. I, also understand that Rhythm Heart Institute will not be responsible for any loss, damage or theft of any Personal Property/Belongings of Me/Patient/Visitors within the Hospital Premises. Including Patients rooms and Parking area. I agree to follow all the rules and regulations of Hospital and clear all the expenses incurred for My/Patient treatment on time as per the Terms and Conditions of Rhythm Heart Institute. I hereby give my consent and authorize Rhythm Heart Institute to process, store , use, disclose my personal or sensitive information /data collected as per Rhythm Privacy policy.

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