Create Hospital Card

Create patient card

Fill in the form below to create patient card

Personal information

First Name*

Last Name*

Other Names

Gender*

Date of birth*

Place Of Origin

Nationality

State of origin*

L.G.A*

Home Town/ Village

Compound

Religion

Occupation

Contact information

Street Address Of Residence*

City/Town Of Residence

State Of Residence

Email Address

Mobile Number*

Office Number

WhatsApp Number

Next of Kins Information

Last Name*

First Name*

Other Names

Gender

Phone Number*

State of origin

Residential Address

Relationship with patient

Other information

First Time In Facility?

Referred?

Choose Hospital*

Remark

Upload Picture

Choose your passport*