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Employee Name
Dashboard
Add Customer
Reports
Logout
Register for Health Card
Customer Name
*
Mobile No
*
Gender
*
Select Gender
Male
Female
Other
Age
*
Year
Address
*
Village/Town/City
*
No.of Family Numbers
*
Select No. of Family Members
1
2
3
4
5
6
7
8
Employee Reference Number
EMP-
Photo Upload
*
Family Members
Family Member Name - 1
Relation
Select Relation
Mother
Father
Spouse
Age
Year
Family Member Name - 2
Relation
Select Relation
Mother
Father
Spouse
Age
Year
Family Member Name - 3
Relation
Select Relation
Mother
Father
Spouse
Age
Year
Children
Children Name - 1
Age
Year
Children Name - 2
Age
Year
Children Name - 3
Age
Year
Children Name - 4
Age
Year
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