Patient registration form for EKG screening at the seminar

CHECK YOUR HEART : Know Your Heart, Care for Every Beat

Screening on Saturday, 26 September 2026 Time 12:00 - 13:00

Fields marked * are required

Title *

First name *

Last name *

First name (English) *

Last name (English) *

National ID / Passport No. *

Date of birth *

Mobile phone *

Nationality *

Address *

Sub-district *

District *

Province *

Postal code *

Additional personal information

Marital status *

Primary language *

Religion *

Occupation *

Emergency contact name *

Relationship to patient *

Emergency contact address (please give full details) *

Phone number *

Attach a photo of your ID card / passport *

JPG or PNG, up to 5 MB