Please
fill in your information as accurately, and completely
as possible.
The fields marked with an * are required to complete
your registration.
|
Name |
*First
Name  |
|
Middle
Name |
|
Maiden
Name |
|
*Last
Name |
|
|
Other Personal Information |
NIC
Number |
|
*Gender |
|
*Marital
Status |
|
*Date of Birth |
|
*Birth
Place |
|
*Residency |
|
*Nationality |
|
Religion |
|
Ethnicity |
|
Medical
Insurance |
|
*Employed |
yes
no
|
Occupation |
|
Employer |
|
Schooling
Level |
|
| |
Contact
Information |
*Primary
Phone |
|
Mobile |
|
Work phone |
|
*Street
Address |
|
*Community |
|
*District |
|
*Country |
|
P.O.
Box |
|
Email |
|
| |
Schooling
Information |
*Attending
School? |
yes
no
|
Name
of School |
|
Grade/Class/Year |
|
| |
Next
of Kin Information |
NIC
Number |
|
Relation
to Patient |
|
First
Name |
|
Last
Name |
|
Primary
Phone |
|
Mobile |
|
Work
Phone |
|
Street
Address |
|
Community |
|
District |
|
Country |
|
P.O.
Box |
|
Email |
|
| |
|
For
more information on how to complete this form please
call the UHC main office at 452-6756 or fax us at
453-7668 or email us at contact@stluciauhc.org.You
may also find downloadable copies of UHC forms and
other useful instructions here.
Once completed, the form may be returned to the
UHC office main office, or to any public health
facility. The contents of this form and any personally
identifiable information submitted will be treated
with strict confidentiality while in possession
of UHC. Presenting false or intentionally misleading
registration information is prohibited by law.
*required
information, to ensure services provided meet the
highest standards
|
|
|
