Patient Registration Form
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Personal Details
2
Contact Details
3
Medical Aid
4
Clinical information
Date of Birth
Male
Female
Married
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Patient
Next of Kin
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Email
Phone
SMS
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Next of Kin
alliance
CELLMED
cimas
flimas
fml
generation health
GENFIN
MAISHA
psmas
Self
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Being treated?
Pregnant?
Been hospitalised?
Do you have any of the following
Heart Disease
Tuberculosis
Rheumatic Fever
Shortness of Breath
Diabetes
Veneral Diseases
Bleeding Disease
Epilepsy Convulsions
High/ Low BP
Allergies
Kidney Disease/ Infection
Liver Disease/ Hepatitis/ Jaundice
HIV
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