Byte Health Registration Form

Byte Health Registration Form

新用户注册表
Patient Name 就诊人姓名*

First Name 名Last Name 姓
Date of Birth 出生日期 *

DayMonthYear
Gender 性别*
Phone Number 手机号*
Email 邮箱*
Address 地址*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicare Number (If eligible) Medicare 号码 (如有)
Medicare Reference Number (If eligible)
Medicare Reference 号码
IHI Number (If has) IHI号码 (如有)
Emergency Contact 紧急联系人姓名

First Name 名Last Name 姓
Emergency Contact Number 紧急联系人电话
Emergency Contact Relationship 与紧急联系人的关系
与紧急联系人的关系
How did you hear about us? 您从哪里知道Byte Health？*
Would you like to schedule a doctor's appointment right now? 您现在需要预约看诊吗？*

YesNo
Should be Empty: