Scribd
Upload
131 views1 page

NHIS Form

This document is a registration form for the National Health Insurance Scheme at Ahmadu Bello University. It requires personal information such as name, date of birth, nationality, and contact details, as well as medical information including blood group and genotype. Additionally, it includes sections for academic details and requires a signature and approval from the Head of Department.

Uploaded by

Ijachi sunday
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
131 views1 page

NHIS Form

This document is a registration form for the National Health Insurance Scheme at Ahmadu Bello University. It requires personal information such as name, date of birth, nationality, and contact details, as well as medical information including blood group and genotype. Additionally, it includes sections for academic details and requires a signature and approval from the Head of Department.

Uploaded by

Ijachi sunday
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

AHMADU BELLO UNIVERSITY

NATIONAL HEALTH INSURANCE SCHEME FORM


(NHIS)
(TO BE COMPLETED IN BLOCK LETTERS) REGISTRATION NUMBER:
A. PERSONAL INFORMATION

SURNAME:
Date of Birth:
MM DD YYYY
FIRST NAME:

MIDDLE NAME: Sex: (Please tick)


Male Female
NATIONALITY:
NEXT-OF-KIN / GUARDIAN:
STATE OF ORIGIN: Names:
Address:
LOCAL GOVERNMENT AREA:
Relationship:
PERMANENT HOME ADDRESS: Phone:

C. MEDICAL:(Please tick as appropriate)


POSTAL ADDRESS: BLOOD GROUP: A AB B O
Other (Please Specify):__________________
TELEPHONE:
GENOTYPE: AA AS SS
E-MAIL: Other (Please Specify):__________________

B. ACADEMIC DETAILS Student Signature:


COURSE:

Affix 2 recent
APPROVAL (HOD SIGN.)
FACULTY: passports here!!!

DEPARTMENT:

LEVEL:

You might also like