When visiting your private doctor, please ask the doctor to prescribe your medication on the approved UHC prescription form                    Only the medication approved by UHC for diabetics and diabetics with hypertension will be available free of charge                    Under the UHC Pilot program only medication pertaining to your diabetes and hypertension is free                    
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UHC Mail
 
Conway Business Centre
Waterfront, Castries
St. Lucia, W.I.

contact@stluciauhc.org
Tel: (758) 452-6756
Fax: (758) 453-7668

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


This information is correct to the best of my knowledge.

 
 
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