Patient Self Registration
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Patient Information
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Patient ID
HS
NY
MB
KS
OD
SD
ED
SU
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Patient IF
Patient Name
Mrs.
Ms.
Mr.
Dr.
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please enter name
The middle name looks good!
please enter name
National ID/ Passport No.
KRA PIN Number
Patient Date of Birth
Patient age (Y)
Occupation
Contact number
Alternate Contact number
Patient Email ID
Marital Status
Married
Single
Relationship
Consent to share the details to partner
Yes
No
Unspecified
Partner Information
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Partner ID
copy id?
HS
NY
MB
KS
OD
SD
ED
SU
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Please enter Husband ID
Partner Name
Mr.
Dr.
Mrs.
Ms.
The first name looks good!
please enter name
The middle name looks good!
please enter name
National ID/ Passport No.
KRA PIN Number
Partner Date of Birth
Partner age (Y)
Occupation
Contact number
Alternate Contact number
Partner Email ID
Consent to share the details to patient
Yes
No
Unspecified
Address Information
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Address
Town/ City
Country
Postal Address
Postal code
Emergency Contact Information
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Emergency Contact Name
Emergency Mobile No.
Emergency Email
Emergency Contact Relationship
Referred By
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Referral Type
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Referral Doctor Name
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Consulting Doctor Name
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Dr. Alfred Murage
Dr. Edgar Gulavi
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