Enquiry Form
Enquiries/Registration /Appointment
To:
NIO ( National Institute Of Opthalmology- Enquiries, Registration)
Appointment
Subject:
Are you an existing patient?
yes
no
Note: For existing patient, you only have to fill-up your email and enquiry.
Personal Information
MRD No:
IC/Passport No* :
Title:
Dr.
Mr.
Mrs.
Ms.
Name*:
Sex:
male
female
Race:
Address*:
Town:
Post Code:
State:
Country:
Phone (Hs):
Phone (Hp):
Date of Birth:
Language:
Occupation:
Doctor:
Another Contact (Relative)
Person Name:
Relationship:
Address:
Phone:
Your Email*:
Your Enquiry:
*Marked fields are not to be left
