Universal Healthcare - Registration Form

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

Registration Form

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