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Alcohol de-addiction Program

Alcohol De-Addiction Program Registration Form

Personal Information

First Name *

Last Name *

Date of Birth*

Gender *

Male

Female

Others

Contact Number *

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Secondary Contact Number

Address

Street *

City/Town *

State *

Pincode *

Emergency Information

Emergency Name *

Emergency Relationship *

Emergency Phone Number *

Alcohol Consumption History

How long have you been consuming alcohol?*

Less than 1 year

1-3 years

3-5 years

More than 5 years

How often do you consume alcohol? *

Daily

Weekly

Occasionally

Binge Drinking (Heavy episodes)

What types of alcohol do you primarily consume? *

Beer

Local Wine

Spirits (Whiskey, Vodka, etc.)

Other

On average, how many drinks do you consume per day? *

1-2 drinks

3-5 drinks

More than 5 drinks

Unable to estimate

Digital Signature

Signature *

Date of Signature *

Additional Comments or Special Requests

I, the undersigned, voluntarily seek assistance for alcohol de-addiction and consent to participate in the treatment program provided. I understand that my information will be kept confidential in accordance with program guidelines.

* required

0361-283 0009

[email protected]

KaviKrishna Telemedicine Care, College road, Kanchan Nagar Rd, Kanchan Nagar, Sualkuchi, Assam 781103, India

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