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Registrant Last Name *

Registrant Address *

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Registrant Pic *

Person to be register Name *

Person to be register Address *

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Register Person Pic *

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Email *

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Who will Be Paying *

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About registered person

Home Phone #

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Medical Information Required

By registering as a client you will need to enter the registered person's medical information in our EMR (Electronic Medical Records) This will allowed doctors in Barbados to understand their medical history and keep an updated record. Access to this restricted area will be granted after your meeting and payment have been received.

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