{"id":463,"date":"2026-10-03T10:16:40","date_gmt":"2026-10-03T10:16:40","guid":{"rendered":"https:\/\/dawagate.online\/patient\/register\/"},"modified":"2026-10-03T10:16:40","modified_gmt":"2026-10-03T10:16:40","slug":"register","status":"publish","type":"page","link":"https:\/\/dawagate.online\/ar\/patient\/register\/","title":{"rendered":"Patient Registration"},"content":{"rendered":"<style>.dg-patient-form{display:grid;grid-template-columns:repeat(3,minmax(0,1fr));gap:18px 20px}.dg-patient-form h1,.dg-patient-form>p,.dg-patient-form>button,.dg-patient-form>.dg-consent{grid-column:1\/-1}.dg-patient-form label{display:flex;flex-direction:column;gap:6px}.dg-patient-form input,.dg-patient-form select{width:100%;box-sizing:border-box}.dg-patient-form .dg-phone-note{font-size:.9em;color:#667783;margin-top:-10px}.dg-patient-form .dg-consent{display:flex;align-items:flex-start;justify-content:flex-start;gap:8px;text-align:left;line-height:1.5}.dg-patient-form .dg-consent input{width:auto;flex:0 0 auto;margin:.3em 0 0}.dg-patient-form .dg-consent span{flex:1 1 auto}.dg-patient-form fieldset.dg-chronic-conditions{border:1px solid #dde8ec;border-radius:8px;padding:14px;display:flex;flex-direction:column;gap:8px}.dg-chronic-conditions .dg-check-row{display:flex;flex-direction:row;align-items:center;gap:8px}.dg-chronic-conditions .dg-check-row input{width:auto;margin:0}.dg-chronic-conditions .dg-other-condition{margin-top:4px}.dg-patient-form button{justify-self:start}@media(max-width:768px){.dg-patient-form{grid-template-columns:1fr}.dg-patient-form h1,.dg-patient-form>p,.dg-patient-form>button,.dg-patient-form>.dg-consent{grid-column:1}}<\/style><form class=\"dg-patient-form\" method=\"post\" action=\"https:\/\/dawagate.online\/wp-admin\/admin-post.php\"><input type=\"hidden\" name=\"action\" value=\"dg_patient_register\"><input type=\"hidden\" id=\"_wpnonce\" name=\"_wpnonce\" value=\"ce36897080\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ar\/wp-json\/wp\/v2\/pages\/463\" \/><h1>Patient Registration<\/h1><p>Register simply and a DawaGate representative will call to help complete your profile.<\/p><label>First Name *<input required name=\"first_name\" maxlength=\"100\"><\/label><label>Last Name *<input required name=\"last_name\" maxlength=\"100\"><\/label><label>Gender *<select required name=\"gender\"><option value=\"\">Select<\/option><option>Male<\/option><option>Female<\/option><\/select><\/label><label>Date of Birth *<input required type=\"date\" name=\"date_of_birth\"><\/label><label>Mobile Number *<input required name=\"phone_e164\" inputmode=\"tel\" placeholder=\"+20...\"><small class=\"dg-phone-note\">Please check that your mobile number is correct. DawaGate will use this number to contact you and help complete your profile.<\/small><\/label><label>Email (optional)<input type=\"email\" name=\"email\"><\/label><label>Governorate *<select required name=\"governorate\" id=\"dg-governorate\"><option value=\"\">Select governorate<\/option><option value=\"Cairo\">Cairo<\/option><option value=\"Alexandria\">Alexandria<\/option><option value=\"Giza\">Giza<\/option><option value=\"Qalyubia\">Qalyubia<\/option><option value=\"Dakahlia\">Dakahlia<\/option><option value=\"Sharqia\">Sharqia<\/option><option value=\"Gharbia\">Gharbia<\/option><option value=\"Monufia\">Monufia<\/option><option value=\"Beheira\">Beheira<\/option><option value=\"Kafr El Sheikh\">Kafr El Sheikh<\/option><option value=\"Damietta\">Damietta<\/option><option value=\"Port Said\">Port Said<\/option><option value=\"Ismailia\">Ismailia<\/option><option value=\"Suez\">Suez<\/option><option value=\"North Sinai\">North Sinai<\/option><option value=\"South Sinai\">South Sinai<\/option><option value=\"Fayoum\">Fayoum<\/option><option value=\"Beni Suef\">Beni Suef<\/option><option value=\"Minya\">Minya<\/option><option value=\"Asyut\">Asyut<\/option><option value=\"Sohag\">Sohag<\/option><option value=\"Qena\">Qena<\/option><option value=\"Luxor\">Luxor<\/option><option value=\"Aswan\">Aswan<\/option><option value=\"Red Sea\">Red Sea<\/option><option value=\"New Valley\">New Valley<\/option><option value=\"Matrouh\">Matrouh<\/option><\/select><\/label><label>City *<select required name=\"city\" id=\"dg-city\" disabled><option value=\"\">Select governorate first<\/option><\/select><\/label><label>Preferred Contact *<select required name=\"preferred_contact\"><option value=\"\">Select<\/option><option value=\"phone\">Phone<\/option><option value=\"whatsapp\">WhatsApp<\/option><\/select><\/label><label>Detailed Address (optional)<textarea name=\"address\" rows=\"3\" maxlength=\"1000\"><\/textarea><small>Please enter your address as clearly as possible. DawaGate may contact you to verify or complete the address details.<\/small><\/label><fieldset class=\"dg-chronic-conditions\"><legend>Common Chronic Conditions (optional)<\/legend><label class=\"dg-check-row\"><input type=\"checkbox\" name=\"chronic_conditions[]\" value=\"Diabetes\"> <span>Diabetes<\/span><\/label><label class=\"dg-check-row\"><input type=\"checkbox\" name=\"chronic_conditions[]\" value=\"High Blood Pressure \/ Hypertension\"> <span>High Blood Pressure \/ Hypertension<\/span><\/label><label class=\"dg-check-row\"><input type=\"checkbox\" name=\"chronic_conditions[]\" value=\"Thyroid Disease\"> <span>Thyroid Disease<\/span><\/label><label class=\"dg-check-row\"><input type=\"checkbox\" name=\"chronic_conditions[]\" value=\"Other\" id=\"dg-chronic-other\"> <span>Other<\/span><\/label><label class=\"dg-check-row\"><input type=\"checkbox\" name=\"chronic_conditions[]\" value=\"None Reported\" id=\"dg-chronic-none\"> <span>None Reported<\/span><\/label><label class=\"dg-other-condition\" hidden>Other chronic condition (optional)<input name=\"other_chronic_condition\" id=\"dg-other-condition\" maxlength=\"190\" disabled><\/label><\/fieldset><label>Previous Surgeries (optional)<textarea name=\"surgeries\" rows=\"3\" maxlength=\"2000\"><\/textarea><small>Please mention any previous major surgeries you remember. You can also provide this information later when DawaGate contacts you.<\/small><\/label><label class=\"dg-consent\"><input required type=\"checkbox\" name=\"contact_consent\" value=\"1\"><span>I consent to DawaGate contacting me and assisting with completing my profile.<\/span><\/label><button type=\"submit\">Submit Registration<\/button><\/form><script>(function(){var data={\"Cairo\":[\"Cairo\",\"Heliopolis\",\"Nasr City\",\"New Cairo\",\"Maadi\",\"Shubra\"],\"Alexandria\":[\"Alexandria\",\"Borg El Arab\",\"Montaza\"],\"Giza\":[\"Giza\",\"6th of October\",\"Sheikh Zayed\",\"Haram\",\"Dokki\"],\"Qalyubia\":[\"Qalyubia\",\"Banha\",\"Qalyub\",\"Shubra El Kheima\"],\"Dakahlia\":[\"Dakahlia\",\"Mansoura\",\"Talkha\",\"Mit Ghamr\"],\"Sharqia\":[\"Sharqia\",\"Zagazig\",\"10th of Ramadan\",\"Belbeis\"],\"Gharbia\":[\"Gharbia\",\"Tanta\",\"Mahalla El Kubra\",\"Kafr El Zayat\"],\"Monufia\":[\"Monufia\",\"Shibin El Kom\",\"Ashmoun\"],\"Beheira\":[\"Beheira\",\"Damanhur\",\"Kafr El 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