Patient Registration Form
Patient Information
Patient's Name *
Date of Birth *
Phone Number *
+234
Enter 10 digits without +234 prefix
Password *
Password must be at least 6 characters long
Confirm Password *
Passwords do not match
Passwords match
Address *
Marital Status *
Select Marital Status
Single
Married
Divorced
Widowed
Type of Illness *
Select Type of Illness
Appendectomy - ₦210,000.00
Breast lump - ₦60,000.00
Herniotomy - ₦110,000.00
Hysterectomy - ₦400,000.00
Inguinal hernia - ₦110,000.00
Lipoma-Big - ₦60,000.00
Lipoma-medium - ₦40,000.00
Lipoma-small - ₦100.00
Myomectomy - ₦360,000.00
Scrotal hernia - ₦110,000.00
Thyroidectomy - ₦400,000.00
Umbilical hernia with mesh - ₦310,000.00
Umbilical Hernia without mesh - ₦210,000.00
Undescended testes - ₦110,000.00
Blood Group *
Select Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Genotype *
Select Genotype
AA
AS
AC
SS
SC
Allergy (if any)
Next of Kin Details
Name *
Date of Birth *
Phone Number *
+234
Address *
Relationship *
Register