EA Register

Contact(Optional)

Email

Please enter a valid email address.

Residency

Please provide a valid Residency.

Preferred Location

Please provide a valid Location.

Occupation

Did you visit American Hospital/Clinic before?

Yes

No

Do you live in labour camp?

Yes

No

Labour Camp Name

LabourCamp Name is required.

Labour Camp Address

LabourCamp Address is required.

Supervisor's Name

Supervisor's Name is required.

Supervisor's Moblie

Enter Supervisor's Moblie.

Occupation Details

Occupation category

Labour

Non-Labour

Occupation

Occupation is required.

Occupation Country

Please choose Occupation Country.

Occupation Emirate

Please choose Occupation Emirate.

Address

Please enter address.

Address 2 (Optional)

Please enter address line2.

City

Please provide a valid city.

Landmark(Optional)

Please enter Landmark.

Home Emirate

Please select emirate.

Next of Kin / Emergency Contact

First name

First name(Next of Kin) is required.

Middle name

Middle name(Next of Kin) is required.

Last name

Last name(Next of Kin) is required.

Mobile

Enter mobile number(Next of Kin).

InCase of emergency, who should contact

Next of Kin Other

Guarantor

Minor age :
Guarantor documents must upload for minor patients.
Either Passport or EID - Number & Attachment mandatory

Passport

Upload 📷

EID

Front 📷

Back 📷

Pre-Registration