Upload your dully filled application form here.
අයදුම්පත මෙම පිටුවට අනිවාර්යෙන්ම UPLOAD කළ යුතුය
FULL NAME IN BLOCK LETTERS:
NAME WITH INITIALS:
CIVIL STATUS: MARRIED /SINGLE.
GENDER: Male / Female
DAT OF BIRTH:
PHONE – MOBILE: LAND:
WEB: USER NAME: PASS WORD:
REFERING SILVER MEMBER’S NAME:
REFERING SILVER MEMBER’S N.I.C NUMBER:
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.
If guardian takes the responsibility of maintaining the membership, details of the guardian.
විසින් සාමාජිත්වය පවත්වාගෙන යාමේ වගකිම ගනීනම්,බාරකරුවාගේ විස්තර
Phone number (In an emergency
contact this number):