Patient Registration - ST MARY’S SPECIALIST CENTRE

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Patient Registration

PROSTATE CARE INITIATIVE
PATIENT REGISTRATION FORM

Personnel can be reached during office hours by calling the main office as listed below. Click here for telephone nos and address.

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* Not Required
First Name:
Last Name:
Email:*
Address_1:
Address_2:
City:
State:
Date Of Birth:
Marital Status:
Telephone Home#:
Cell#:
Work#:
Referred by:
Next of Kin Full Names:
Address:
Telephone:
Employer Name:
Address:
Telephone:
Preferred Pharmacy Name:
Address:
Emergency Contact Name:
Address:

I hereby assign payment directly to BAGNES NIGERIA LIMITED for medical benefits payable for these PROSTATE CARE INITIATIVE services. I understand I am responsible for payment of all services rendered.
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Clinic Office Hours: 9:00am to 5:00pm Monday - Friday HOSPITAL ADDRESS ST. MARY'S SPECIALIST CENTRE 11 TAORIDI STREET SURULERE LAGOS, NIGERIA Telephone: 234-1-8922649, 234-1-08033203933