Monday, September 06, 2010
   
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Patient Registration Form
  1. Important Instructions:
    To register for the European Medical Assistance Programme (EMAFA) of the EuroAfricaCentral Network Germany, please fill the form below. Please follow the instructions carefully. Note to answer all questions appropriately. Please note: All fields marked with * must be filled out. Please use the scroll-bar on the right to navigate to the buttom or to the top of the Registration form.
  2. Title
    Invalid Input
  3. Date of Birth (*)
    Date of birth!
  4. Name and Surname(*)
    Your name & surname!
  5. Firm
    Invalid Input
    ...If an organisation please write here complete name of org.+ name/(s)of the responsible persons in charge.
  6. Address(*)
    Your address!
  7. Postal Code (*)
    Postal code!
  8. Town(*)
    Your town!
  9. Country(*)
    Your country!
  10. e-mail address (*)
    Your e-mail address!
  11. Web site
    Invalid Input
  12. Telephone number(*)
    Telephone number!
  13. Cell phone (*)
    Cellphone!
  14. Fax Number
    Fax Number

  15. Patient: Please give FULL details about yourself and finally, information about your general health condition below.

  16. Languages spoken (*)
    Languages spoken!
  17. Last Educational Qualification(*)
    Last educational qualification!
  18. Patient Details /Height(*)
    Height of patient!
  19. Patient Details /Weight(*)
    Weight of patient!
  20. Patient Details /Status
    Your marital status!
  21. Present occupation(*)
    Present occupation!

  22. Please check any of the following if they are important to you.

  23. Special wishes









    Please complete details on wishes above!
  24. Patient details /complaints(*)
    Patient details /complaints!
    Please describe shortly and very precisely your present complaints and symptoms including present therapy.
  25. Allergy or disease? details(*)
    Write known allergy or disease?
    If yes, - Any known allergy or disease? Please give complete details here in box.

  26. Next of Kin: Please give accurately as possible complete information about your (In case of emergency ) Next of Kin below.

  27. Kin/Name/Phone(*)
    Next of Kin/Name/Phone
  28. Kin/Cell Phone(*)
    Kin/Cell phone!
  29. Kin - Address(*)
    Next of Kin address
  30. Kin/Fax Number
    Kin/Fax number
  31. Escort person details
    Escort person details!

  32. Your Doctor: Please give accurately as possible complete detailed information about your private physician (your doctor) below

  33. Doctor /Cell Phone(*)
    Physician /Cell phone
  34. Your Doctor´s /Name/Phone(*)
    Physicaian/name/phone!
  35. Doctor´s Address(*)
    Physician - address!
  36. Doctor Fax Number(*)
    Doctor fax number!
  37. Doctor /E-mai(*)
    Doctor E-mail!

  38. Logistics: To facilitate timely/correct preparation, we need detailed information for Planing and Logistics. Please answer all questions.

  39. Travel) date(*)
    Planing /(travel) date to Germany!
  40. Duration of stay(*)
    Duration of stay
  41. Upload Passport Page1
    Upload passport page1!
  42. Upload passport page2
    Upload Passport Page2!
  43. Upload passport page3
    Upload passport page3!
  44. Patient Photo Upload
    UploadpPatient photo!
  45. Upload CV/Resume
    Upload CV/Resume!
  46. Upload Finance Evidence
    Upload financial evidence / letter from sponsor etc!
  47. Upload Medical document
    Upload medical document!

  48. Bank Details: Please write below the details of your Bank Account -This is vital  for formalities to process your application by the Authorities

  49. Bank Name(*)
    Bank name!
  50. Bank account holder(*)
    Bank account holder!
  51. Bank account number(*)
    Bank account number!
  52. Bank Code/Zip(*)
    Bank code/zip!
  53. Bank address(*)
    Bank address!
  54. Other comments
    Invalid Input
  55. How did you know about us?(*)
    How did you know about us?
  56. Today´s Date (*)
    Today´s date!

  57. Terms Accepted: Through clicking on send button, I hereby accept the EAC Terms of Service and submit that I am 18 or above and that all my submision on this form is true to the best of my knowledge.

  58. Secutrity Code
    Secutrity CodeRefreshPlease fill in the security code!
  59.   

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EuroAfrica Medical Assistance For Foreigners & Africans - All rights reserved.

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