Registration form for the Family up to 5 persons Plan

Instruction

Once you've finished filling the Registration form, you will be directed to our Registration Payment page. You are required to pay an annual registration fee of =N=10,000.00. Please complete the form and payment process, which will activate your account.

1. Primary Contact Information

First Name

Last Name

Email Address

Phone Number

Street Address

City

State/Province

Country

Dependent Information (for up to 4 dependents)

Patient 1:

First Name

Last Name

Relationship to Primary Contact

Date of Birth

GenderMaleFemale

Email Address (Optional)

Phone Number (Optional)

Patient 2:

First Name

Last Name

Relationship to Primary Contact

Date of Birth

GenderMaleFemale

Email Address (Optional)

Phone Number (Optional)

Patient 3:

First Name

Last Name

Relationship to Primary Contact

GenderMaleFemale

Date of Birth

Email Address (Optional)

Phone Number (Optional)

Patient 4:

First Name

Last Name

Relationship to Primary Contact

GenderMaleFemale

Date of Birth

Email Address (Optional)

Phone Number (Optional)

Frontdesk: 07069498182 Telehealth: 08058239923

info@emc2clinics.com

Road 22 House 30, Ikota Villa Estate, Lekki, Lagos.

Instruction

Once you've finished filling the Registration form, you will be directed to our Registration Payment page. You are required to pay an annual registration fee of =N=10,000.00. Please complete the form and payment process, which will activate your account.

1. Primary Contact Information

Dependent Information (for up to 4 dependents)

Patient 1:

Patient 2:

Patient 3:

Patient 4:

Hello world!

House 30, Road 22, Ikota Villa Estate, Lekki, Lagos.

Monday-Sunday 24/7

info@emc2clinics.com

Frontdesk: 07069498182, Telehealth: 08058239923