Patient Registration

Step 1 - Patient Information

Name Prefix*

Mrs

Miss

Mstr

Name of Patient*

First Name

Last Name

Date of Birth*

Click on the icon to select a date

Gender*

Occupation of Patient*

Nationality*

Please select the nationality of patient.

Mauritian ID Card Number*

Passport Number*

Scan of your Passport*

Scan of your ID*

What is the patient visa status in Mauritius?*

Expatriate residing in Mauritius

Foreign Student

Tourist

Step 2 - Patient's Contact Details

Residential Address*

City*

Residential Phone Number

Mobile Phone Number*

Are you a Mauritian resident?*

Yes

Phone Number in Mauritius*

Address in Mauritius*

City*

Email address*

Email communication

I do not wish to receive any email from WELLKIN HOSPITAL

Step 3 - In case of Emergency

Consultant's Name*

Name of the person to contact in case of emergency*

Type the full name of the person

Phone Number *

Phone Number to contact in case of emergency.

Relationship*

Father, Child, Friend, Friend, etc...

Patient Visit at Wellkin

Have you been referred by a general practitioner or an hospital / clinic ?

Yes

Name of the person or organisation that referred you?*

General Practitioner, Hospital, Clinic, etc...

Do you have any special requests during your stay at Wellkin?

Quiet room to pray, restricted visit, etc..

Step 5 - Agreement

Name of person providing information

Please type the first name and last name.

Name as the person filling this form

Please type the first name and last name.

How did you hear about Wellkin Hospital?

Do you certify that the information I have provided is true?*

Yes

Agreement*

I agree to the privacy policy and to be contacted by Wellkin Hospital

MSCL takes privacy laws to protect your personal information very seriously. All information provided to MSCL will be treated as confidential. Only authorised personnel will be given access to it. This information will not be made public, sold or provided to third parties without your express authorisation. Read our Privacy Notice for more information.

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