Ahsen Care – Early Access Enrollment Form

1. Personal Information

Photo or ID

Click to upload photo or ID JPG, PNG, WEBP up to 5MB

Full Name *

Phone Number *

Age *

Gender *

Male

Female

2. Location Details

City *

District/Area *

3. Employment Information

Employment Status

Government Employee

Private Company Employee

Business Owner

Employer/Organization Name

Monthly Income Range

Below $200

$200 – $500

$500 – $1,000

Above $1,000

4. Healthcare Needs

How often do you or your family need healthcare services?

Rarely

Occasionally

Frequently

Do you have any chronic disease

Yes

No

5. Payment Preferences

Preferred repayment period:

1 month

3 months

6 months

12 months

6. Employer Partnership (Optional)

Does your employer support salary deduction for services?

Yes

No

Not sure

7. Additional Information

How did you hear about Ahsen Care?

Social Media

Friend/Family

Marketing Team

8. Consent & Agreement

I confirm that the information provided is accurate. ✓

I agree to be contacted by Ahsen Care for early access, updates, and offers. ✓