New Patients

Patient Registration

Complete your registration online in just a few minutes. Your information is kept private and secure.

Section 1

Personal Information

Tell us about yourself.

Full Name (First, Middle, Last) *

Date of Birth *Nationality *

Residential Address *

District *Province *Phone NumberCell Phone Number *Sex *Marital StatusOccupationNRC / Passport Number

Section 2

Next of Kin Information

Who should we contact on your behalf?

Primary Next of Kin

Full Name *Relationship to Patient *

Address

SexContact Phone Number *

Secondary Next of Kin

(Optional)

Full NameRelationship to Patient

Address

SexContact Phone Number

Section 3

Declaration

Please review and confirm.

I certify that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used for patient registration and administrative purposes at Pharco Life Medical Centre.

I confirm that the information provided is correct.