Beneficiary Registration Form Beneficiary Registration Form 1. Name of patient: 2. Gender Male Female3. Age: 4. Full Address: 5. Phone Number 6. Name Of Next Of Kin 7. Treatment History / Diagnosis 8. Name of Treatment Centre And Address 9. Premises License Number of Treatment Center And Heathcare Giver's Name 10. Practice License of Healthcare Giver 11. Phone number (please include country code) of Healthcare Giver 12. List Of Drugs Required 13. Please upload the scanned copy of the prescription 14. Check reCaptcha: Send
