Liver Patient Registration and Support Request Form

Ben Kijuu Foundation - Supporting Liver Cancer Patients

Before You Begin:

Please fill out all required fields marked with *
Have your medical reports and ID documents ready for upload
This form will take approximately 10-15 minutes to complete
You'll receive a confirmation email after submission

1 Personal Information

Full Name *

Gender *

Male

Female

Other

Date of Birth *

Age * Auto-calculated from date of birth

Blood Group

National ID / Passport No. *

Contact Number *

Email Address * You'll use this to login and check your status

Create Password * At least 8 characters with uppercase, lowercase, and number

Confirm Password *

Address *

City *

State / Province

Postal Code

Emergency Contact Information

Emergency Contact Name *

Relationship *

Emergency Contact Number *

4 Documents Checklist

Please upload the following documents:

Copy of ID Proof (National ID or Passport) *

Recent Medical Reports (LFT / Ultrasound / Biopsy / CT / MRI) * You can select multiple files

Income Proof / Salary Slip

Doctor's Certificate / Referral Letter *

Insurance Card Copy (if applicable)

Passport-size Photograph *

5 Declaration and Consent

I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that false information may result in withdrawal of support.

I authorize the medical and support team to verify the submitted information and contact my healthcare provider if necessary.

* I agree to the above declaration and consent

Patient / Guardian Name *

Date *

Note: By submitting this form, you're creating an account. You'll receive login credentials via email to track your application status.

Please review all information before submitting. You'll receive a confirmation email shortly.

Liver Patient Registration and Support Request Form

Before You Begin:

1 Personal Information

Emergency Contact Information

2 Medical Information

3 Financial and Support Request Details

4 Documents Checklist

5 Declaration and Consent

Frequent Questions

Liver Patient Registration and Support Request Form

Before You Begin:

1 Personal Information

Emergency Contact Information

2 Medical Information

3 Financial and Support Request Details

4 Documents Checklist

5 Declaration and Consent

Frequent Questions

What should I do if I think I have symptoms of liver cancer?

How can I support someone with liver cancer?

How can I donate?