|
|
| Patients
Information |
| Name of patient: |
Last
Name
|
| Sex: |
|
| Birth Date: |
Month
Date
Year
|
| E-mail |
|
| Telephone numbers(s) -please include area
code: |
Day Time
Night Time
Other
|
|
Do
you have a medical file number at KFH-Madina
Hospital?
Yes
No
|
| Doctor
Requested: |
|
| Date of Desired Appointment: |
|
Note:
Please be informed that this is only an appointment request. Our
staff will call you back to confirm your appointment
arrangement. |
|
|
