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User Information
Personal Details
Full Name -
Email Address-
Password
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At least eight characters, with at least one lowercase and one uppercase letter.
Phone Number-
Gender -
Female
male
others
Address-
Pincode -
Aadhar Number -
Date of Birth -
Blood Group -
-select blood group
A+
B+
AB+
A-
B-
AB-
Medical History
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medication, pills or drugs?
Do you use Tobaco
Do you use controlled substances
Are you allergic to any of the following
Asprin
Penecilin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa Drugs
others
Do you have any of the following
1.
AIDS/HIV positive
2.
Alzheimers Disease
3.
Anemia
4.
Anigma
5.
Arthiritis
6.
Artificial Heart Valve
7.
Artificial Joint
8.
Asthama
9.
Blood Disease
10.
Blood Transfusion
11.
Blood Problem
12.
Bruise Easily
13.
Cancer
14.
Chemotherapy
15.
Chest Pains
16.
Cold Sores
17.
Cortisone Medicine
18.
Diabetes
19.
Drug Addiction
20.
Easily Winded
21.
Excessive Bleeding
22.
Excessive Thirst
23.
Frequent Cough
24.
Frequent Diarrahea
Emergency Contact
Contact Name:
Contact Number
Contact Address
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Attach Your Prescriptions
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