Patient Registration Form
Clinic name: ______________________________
Date: ______________
OP No.: ______________
Patient Name
Age
Sex
Phone
Address
Occupation
Chief Complaint
Medical History
Tick any that apply
Jaundice
High Blood Pressure
Heart Diseases
Bleeding Disorders
Hemophilia
Allergy
Anemia
Fits
Asthma / RS Disorders
Thyroid
Diabetes
Kidney Diseases
Pregnancy / Lactating
Allergies or other conditions
Consent
I hereby give consent to the doctor and those under their professional supervision to prescribe and perform whatever treatment, operation, anesthesia or other procedure which is deemed necessary or appropriate and mutually agreed upon.
Patient Signature
Date
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