King Abdullah bin Abdulaziz University Hospital

Patient Access Form - Lung cancer early screening Program

Requester Details: ( Requester Full Name & kinship relationship )

First Name

Last Name

Kinship relationship

Patient Details: ( Patient Full Name )

First Name

Father Name

Grandfather Name

Family Name

Date of Birth

Place of Birth

Saudi ID / Iqama No / Passport

Gender

Male

Female

Nationality

Marital Status

Preferred Language

Arabic

English

Address

Counrty

City

Mobile No

Important Note: Please enter your mobile number accurately. We will contact you through it

Emergency Contact

Full Name

Kinship

Mobile No

Today Date: 12 June, 2025

Required Patient Documents

Copy of ID/Iqamaa /Passport/Family card

Note: you can attach .pdf files and images only- Maximum size 4 MB

Terms and Conditions ( Acknowledgement )

I ...... mentioned above , acknowledge that all information and documents provided by me are accurate and correct, and I take full responsibility for them.

Acknowledgement

How did you know about the program?

Note: Submission will last for a few seconds to upload attached files

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Patient Access Form - Lung cancer early screening Program

Requester Details: ( Requester Full Name & kinship relationship )

Patient Details: ( Patient Full Name )

Required Patient Documents

Terms and Conditions ( Acknowledgement )

Login With Patient Mobile

Patient Referral

Login With Doctor Email