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Aifya Beta Tester
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Register Patient
Demographics
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Gender
*
Male
Female
Other
National ID / Passport
Contact Information
Phone Number
*
Alternate Phone
Email Address
Address
County
Sub-County
Ward
Village/Estate
Postal Address
Next of Kin
Next of Kin Name
Next of Kin Phone
Relationship
Insurance
SHA Number
Insurance Provider
Member Number
Medical Information
Blood Group
—
A+
A-
B+
B-
AB+
AB-
O+
O-
Register Patient
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