Add New Patient

Personal Details

Core demographics and identity of the patient

Step 1 of 7

Photo

JPG / PNG · max 2MB

First Name *

Last Name *

Date of Birth *

Marital Status

Gender *

Male Female Other

Patient Type

Nationality

Preferred Language

Identification

Government-issued identity for verification

ID Type

ID Number

Issue Date

Expiry Date

Contact Information

How the hospital will reach the patient

Mobile Number *

Alternate Number

Email Address *

WhatsApp Number

Address

Residential / correspondence address

Address Line 1

Address Line 2

City

State / Province

ZIP / Postal

Country

Physician Assignment

Route the patient to the right department & doctor

Department

Assigned Doctor

Room Preference

Admission Type

Insurance Details

Coverage & verification for billing

Verification Ready

Provider

Policy Number

Coverage Type

Expiry Date

Coverage Amount

Verification Status

Upload Insurance Card

Drag & drop or click to browse · front & back

Emergency Contact

Who to reach in a critical situation

Contact Person

Relationship

Mobile Number

Alternate Number

Address

Preferred Hospital Contact

Document Upload

Attach supporting documents · drag & drop supported

6 slots

Patient Photo

JPG / PNG

Government ID

Front & back

Insurance Card

Image / PDF

Medical Records

PDF preferred

Referral Letter

From physician

Previous Reports

Labs / scans

Review & Submit

Confirm the details before registering the patient

Identity

New Patient

Demographics & ID captured

Clinical

Medical history

Vitals, allergies & meds

Coverage

Insurance

Provider & verification

I confirm the information provided is accurate and the patient has consented to data processing under the hospital privacy policy & applicable regulations.

Personal Details

Identification

Contact Information

Address

Medical Information

Physician Assignment

Insurance Details

Emergency Contact

Document Upload

Review & Submit