Registration Form

  • 1 Basic Information
  • 2 Medical Information
  • 3 Terms and Conditions

Enter the Basic information

Enter the Medical information

Details of Health/Social Security(optional)

Policy Details Policy 1 Policy 2
Insurance Company
Ceiling
Type of Policy
Policy Number
Date of expiry of the policy/policies

Name of Next of Kin (NOK) with details

Name Relationship Age Address Mobile
Any Other preferences or information you would like to provide

Certificate

(Please click on finish button if you agree with our conditions)

I certify that the information given above is true to the best of my knowledge and belief.
I undertake the responsibility of informing Doorstep Health Services of any change in the above at any time in the future.
I hereby give my consent for provision of healthcare and related services to me /and my dependent members by Doorstep Health Services. The information given here is confidential but may be divulged in case of any medico legal.
I agree to pay for services utilized for myself/and for my dependent members promptly as per the rates decided by Doorstep Health Services. I also authorize my family members or NOK to pay on my behalf.
I agree that these services may be discontinued if I do not comply with standard medical and administrative requirements.
I agree that I will utilize these services for the registered member only. I understand that in case of a drug reaction to any drug for the first time/or for drugs for which no information has been provided by me, Doorstep health services would not be responsible.