Personal Information given in the application form - අයදුම්පතෙහි සඳහන් පෞද්ගලික තොරතුරු

Upload your dully filled application form here.
අයදුම්පත මෙම පිටුවට අනිවාර්යෙන්ම UPLOAD කළ යුතුය

FULL NAME IN BLOCK LETTERS:

NAME WITH INITIALS:

ADDRESS: 

PROFESSION:

CIVIL STATUS: MARRIED /SINGLE.   

N.I.C. NUMBER:  

 GENDER: Male  /  Female

DAT OF BIRTH:   AGE:

PHONE – MOBILE:     LAND:  

E-MAIL: 

WEB: USER NAME:   PASS WORD:

REFERING SILVER MEMBER’S NAME: 

REFERING SILVER MEMBER’S N.I.C NUMBER: 


I hereby give the consent to proceed considering me as a patients and CHIRA-JEEWA medical service as the medical service provider to safeguard my good health. Further I authorize the release of a full report of clinical history, examination findings, investigatory findings, diagnosis, and treatment, follow up plan etc., to any referring or treating physician or dentist on my request. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims on my rquest. I understood that I am responsible for all charges for services given to me regardless of insurance coverage. I hereby certify that the medical information given is true and correct. Further I understood the benefits of maintaining my up dated health profile in a personal web page and thus I give the permission for that.

Full signature of Applicant / Guardian.   

D

D

M

M

Y

Y

Y

Y

 

     Date  


 

If guardian takes the responsibility of maintaining the membership, details of the guardian.

බාරකරුවා විසින් සාමාජිත්වය පවත්වාගෙන යාමේ වගකිම ගනීනම්,බාරකරුවාගේ විස්තර  

Name:

E-MAIL: 

Relationship: 

Phone number (In an emergency contact this number): 

Address: 


 


Service agreement - සේවා ගිවිසුම. 


 

Terms and conditions - කොන්දේසි සහ රීතීන්. 


Privacy policy - පෞද්ගලිකත්වය /රහස්‍යභාවය.

 


List of other C-J members linked to this account - මෙම ගිණුමට සම්බන්ධිත වෙනත් චිර - ජීව සාමාජිකයින් ලැයිස්තුව. 


 

This page displys important details about the members linked to the accounts of GOLD-MEMBERS(Family Doctors), SPECIALIST DOCTORS,  SILVER-MEMBERS or FAMILY LEADERS. For the GOLD-MEMBERS and for others, they can view the member's health informations with the permission of relevant member. But for the SILVER-MEMBERS, they can view only contact details and health score chart of relevant member.

List of Members linked to this parent account.

 

No.   -NAME -  MEMBERSHIP NUMBER-     PHONE-    ADDRESS-    E MAIL-   ACTIVE/NOT ACTIVE

 

1.

 

2.

 

3.

 

4.

 

5.


 

 

 

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