Registration Form S-E
To,

Hello….. Greetings from term of ZEMO Solutions Pty. Ltd.

We expect you in sound and prosperous health & promise you for enrichment of the same.

It is our great pleasure to receive F-E form which is indicative of our future association and your interest of medical tourism.

We assure you for your enjoyable comfortable and memorable time while to be with us.

For your well planned medical and tourist schedule organization and your smoother and hurdle less stay in fulfilling the goal of your visit in decided route and schedule, we will require other details of the patients / visitor.

This will aid us for effective utilization of your time, money and energy with maximum reward and pay.

Please fill up this S-E form for further proceedings.
Name : Age :
Chief complains :
No. Complaint Duration Any treatment taken
1
2
3
4
5
What Medicine you are taking currently ? :
Do you have ? :
Pulse Rate :
Blood Pressure : Systolic Diastolic
Blood Suger :     Fasting      PPBS
Temperature :
Have you gone through any major operation? If yes then mention with duration :
No. Name of Operation When Operated Place of operation
1
2
3
4
5
Do you have allergy of any drug?
No. Name of Drug
1
2
3
4
Diet :
Veg Non-Veg
Habits :
Smoking :
Tobacco :
Alcohol :
Other :
Blood Group : Who is your family physician ? :
Do you have medical Insurance : Yes No  
When are you visiting to India ? :  
For how many days, You will stay here? :  
Write down your suggested schedule for medical tourism on our part :