SC-Patient Registration Form

Patient Registration Form

Please fill in the form below
Name*

First NameMiddle NameLast Name
Gender*
Date of Birth*

MonthDayYear
Complete Address*

Street Address

District

CityArea

Country
Primary Contact :*

Area CodePhone Number
Secondary Contact

Area CodePhone Number
E-mail*
Nationality*
Marital Status*
Proof Of Identity*

Emirates IDPassport NoGCC IDDriving LicenseOther
ID Number*
Occupation*
Insurance Company*
Emergency Contact Person*

First NameMiddle NameLast Name
Emergency Contact Number :*

Area CodePhone Number
Would you like to be reminded about your next appointment?*

YesNo
If yes, please select the mode of reminder*

CallSMSWhatsappE-mailCalender ReminderOther
How did you hear about our clinic? Please chose from the following options*

Google / WebsiteFamily / FriendPractitionerFacebook / InstagramSwiss TowerLift Screen AdvertDr. Rabih Abi Nader WebsiteDutch Dentist WebsiteSpanish Dentist WebsiteSwiss TowerAPCGerman International SchoolMagazine / Newspaper / FlyerExpat AktuellOther
Please write name of the practitioner or School, If applicable

Consent To NABIDH
The NABIDH HIE is a medium that allows your health information to be shared by participating providers including medical groups, hospitals, labs, radiology centers, and other health care providers through secure, electronic means.
I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies

YesNo
Participation is voluntary and will not affect your ability to receive medical care. If you optout, the NABIDH will block access to your health information even for emergency treatment.

This means that it may take longer for your healthcare providers to get the medical information they may need to treat you. Even if you do not want to participate in NABIDH, Emirate of Dubai law reporting requirements will still be fulfilled through Public Health Registries and research. This means your health information will be used anonymously

Patient Registration Form