PRE-REGISTER

Your first visit to Key Imaging can start before you walk through our doors.

Pre-register your basic details now, so there's less paperwork when you need us.

Patient Registration Form

First and middle name(s)*

Last name / Surname*

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Other

Email address*

Phone Number (WhatsApp preferably)*

Do you have health insurance?*

Yes

No

Name of Health Insurance provider

How did you hear about us?

Search Engine

Social Media

Word of mouth

Other

Please tick if you would like to receive occasional health information, service updates and events from Key Imaging.

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