HealthAlpha - Pre-Registration Form

Pre-Registration Form

Please fill in your details to get started with HealthAlpha

Full Name (as per ID) *

Gender *

Date of Birth *

Mobile Number *

Email Address *

Create Password *

Confirm Password *

Country *

State *

City / Town *

Pin Code *

Address (Optional)

Optional but helps personalize your experience

Height (cm)

Weight (kg)

Blood Group

Allergies (if any)

Current Medications

Existing Health Conditions

Emergency Contact Name

Emergency Contact Number

Preferred Language *

Communication Preference *

How did you hear about HealthAlpha? *

Referral Code (if applicable)

I agree to the Terms & Conditions and Privacy Policy *

I consent to share my health data with HealthAlpha for personalized healthcare services *

Subscribe to HealthAlpha updates and health tips (optional)