Registration

Register Your Patient

Complete the form below to request home nursing services.

Patient Registration Form

1. Applicant Information

First Name * Last Name * Contact Number * 2nd Contact Details Emergency Contact Details * Relationship with Patient *

2. Patient Information

Patient's Full Name * Date of Birth Age Gender * Permanent Address NIC No. Recent Hospital

3. Medical History

Present Complaints Past Medical History Past Surgical History Allergies History

4. Guardian Information

Guardian's Full Name Relationship to Patient NIC No. Phone Number Permanent Address

5. Payment Details

Contract Start Date & Time Contract End Date & Time Service Type

6. Declaration

Name NIC

Service Rates

Caregiver: Rs. 4,500/day
Long term (monthly) care: Rs. 4,000
Nursing assistant: Rs. 5,700/day
Professional nurse: Rs. 8,500/day
Service type: Living assistant / shift care

Seneha Priority Membership Benefits

Thank you for considering Seneha Nursing for home nursing services. We understand your request for a caregiver or nurse to manage the condition. Our well-trained and experienced caregivers specialize in personal care, providing personalized support.

✓ Priority access to experienced caregivers and nurses
✓ Discounted rates on long-term care services
✓ Flexible scheduling and service customization
✓ 24/7 support and emergency care coordination
✓ Regular health check-ins and care plan reviews