Patient Registration

Do You Have Insurance?* Yes No

First Name*

Family Name*

Email address*

Contact No*

I am creating this account for* Self Someone Else

Gender*

Enter Your Address*

Enter Your Postal Code*

Enter Your City*

Select Your Canton*

Enter Your Country*

Date of Birth*

Password*

Hint : Password must contain 1 upper case letter , 1 lower cases letter , 1 special character and one number.

Confirm Password*

Insurance Number*

807560

Please upload insurance card image*