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Patient*

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Email*

Existing Patient?*

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Hospital Number (HN)

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I voluntarily agree to allow the healthcare staff at Hospital to provide care, treatment and procedure according to the standard of practice. I also agree to the healthcare staff access my health information in regard to the provided care, treatment and procedure. I acknowledge and understand that I have been informed about “Patient Rights” and “Privacy Policy”

I hereby acknowledge and consent the Hospital to send information about products, services, advertisements, or promotional programs that will benefit me via all channels I have given to the Hospital.*

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