Medims

Privilege Card Holder Registration

Please fill in all the required details to register for a clinic privilege card

Full Name *

Phone Number *

Date of Birth *

Gender *

Dependents (Up to 4)

Please provide details for each dependent covered by this card.

For each dependent, provide date of birth.

Complete the card holder information above to enable dependent details.

Dependent 1

Enter complete details for this dependent.

Full Name *

Phone Number

Date of Birth *

Relation with Card Holder

All fields marked with * are required. Your information will be kept confidential.

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