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Type of Patient
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Private
Entitle
Panel
Personal Information
Title
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Select Title
Mr.
Mrs.
Miss
Dr.
Prof.
Not Applicable
Title Prefix
First Name
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Middle Name
Last Name
Guardian
Son of
Daughter of
Wife of
Marital Status
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Widow
Single
Married
Divorced
Gender
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Male
Female
All
Blood Group
No Blood Group Selected
A+
A-
B+
B-
O+
O-
AB+
AB-
CNIC / Passport
*
CNIC No
Passport No
CNIC No
*
Other CNIC
*
Passport No
*
Date of Birth
*
Age
*
Years
Months
Days
Password
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Confirm Password
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Reference ID
Upload Image
Contact Information
Country
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Select Country
Pakistan
State/Province
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Select Country First
City
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Select State Or Province First
Address
*
Mobile No
*
Telephone No
Email
*
Occupation
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Next of Kin
First Name
Last Name
Relation
Select NOK Relation
Father
Mother
Brother
Sister
Son
Daughter
Spouse
CNIC No
Mobile No