_ UHC Registration Form
 
Welcome
About UHC
Job Opportunities

Admin Reports
Help Desk
UHC Mail

Conway Business Centre
Waterfront, Castries
St. Lucia, W.I.

contact@stluciauhc.org
Tel: (758) 452-6756
Fax: (758) 453-7668

Please fill in your information as accurately, and completely as possible.
The fields marked with an * are required to complete your registration.

_Name

*First Name
Middle Name
Maiden Name
*Last Name
_Other Personal Information
NIC Number
*Gender
*Marital Status
*Date of Birth
*Birth Place
*Residency
*Nationality
*Religion
*Ethnicity
Insurance
*Employed
yes no
Occupation
Employer
Schooling Level
 
_Contact Information
*Primary Phone
Mobile
Work phone
*Street Address
*Community
*District
*Country
P.O. Box
Email
 
_Schooling Information
*Attending School?
 yes no
Name of School
Grade/Class/Year
  
_Next of Kin Information
NIC Number
Relation to Patient
First Name
Last Name
Primary Phone
Mobile
Work Phone
Street Address
Community
District
Country
P.O. Box
Email
   
For more information on how to complete this form please call the UHC main office at 452-6756 or fax us at 453-7668 or email us at contact@stluciauhc.org.You may also find downloadable copies of UHC forms and other useful instructions here. Once completed, the form may be returned to the UHC office main office, or to any public health facility. The contents of this form and any personally identifiable information submitted will be treated with strict confidentiality while in possession of UHC. Presenting false or intentionally misleading registration information is prohibited by law.

*required information, to ensure services provided meet the highest standards

This information is correct to the best of my knowledge.

 
 
Copyright 2007 Universal Health Care. All rights reserved.