Patient Registration

Basic demographic and contact information

Full Name *

Date of Birth *

Gender *

Phone Number *

Ghana mobile number format

Email Address

Home Address

Region *

District

Primary contact person in case of emergency

Emergency Contact Number *

Contact Person Name

Relationship

Essential medical details for emergency care

Blood Group *

Known Allergies

Separate multiple allergies with commas

Chronic Conditions

Include ongoing medical conditions that require management

Current Medications

Include prescription medications, supplements, and over-the-counter drugs

Health insurance and coverage details

Insurance Provider

Insurance Status

Insurance Number/Policy ID

Assign patient to a primary healthcare facility

Primary Facility *

Select the primary healthcare facility where the patient will receive most of their care

Please review all information carefully before submitting. A unique Patient ID will be generated upon successful registration.