Pre-Registration

To save time at the clinic please complete and submit the following form:

	Personal Details
*	Email:		Your email address
*	Family Name:		Your family name
	Middle Name:		Your middle name
	Known As:		Name you are known as
*	Given Name:		Your given name
*	Date of Birth:	/ /	dd/mm/yyyy
*	NRIC/FIN No:		or Passport or Birth Cert no.
*	Nationality:
*	Marital Status:	Single MarriedDivorcedDefacto
*	Gender:	Female Male

	Address Details
*	Temporary Address:	NoYes
*	House/Blk:
*	Street:
	Floor/Unit No:
	Building Name:
*	City:
*	Post Code:
*	Country:

	Contact Details
*	Home Tel No:
*	HP No:		Your Mobile No.
	Work Tel No:
	Fax No:

	Next of Kin
	Name:
	NRIC / Fin No:
	Date of Birth:	/ /	dd/mm/yyyy
	Relationship:		Their relationship to you
	Contact:		How to contact your next of kin
	How did you hear about us:		How did you hear about CHI

	Keep in Touch
	Yes! I would like to receive regular updates.


		* Mandatory field