Registration Form F-E
Patient Name:
Patient ID : Medical Record No. :
Case :
Address :
City : Pin :
State : Country :
Phone (O) : Phone (R) :
Mobile : Fax :
Email :

To,

CEO,
ZEMO Solutions Pty. Ltd.
Sex : Date of Birth : (dd/mm/yyyy)
Blood Group : Age : (In yrs.)
Identification Mark :
ID Card : ID Card No. :
Height (ft) : Weight :
Religion : Language :
Nationality : Occupation :
Who is visit to India? : Self                Relative
If Reletive, then mention Relation :
Purpose of Visiting India : Medical / Health Issue
Tourism
Medical / Health + Tourism

Dear Sir,

I have gone through your website and after studying details of your website. I would like proceed for further formalities of medical tourism.

I am sending my primary information with this. Waiting for your favourable communication and reply.

Please guide me for further procedure.