Patient Information
first name
second name
last name
sex
birth date
education
national id

*Names should be english alphabets without a space
*Date of Birth should always be when the person is born, not future date or false date
*If the person has no education, please leave blank, or else select the appropriate level of education
*National ID should be the exact persons National Digital ID number, please confirm before saving and moving to next task
Patient Address
kilel
kefle ketema
wereda
house number
telephone
email
*Kilel is patients origin as stated on the national ID, please use numerical input only
*Kefle Ketema is for addis ababa resident patients, please use alphabets
*House number should be numeric data, as stated on National ID
*Patient should provide active telephone number
*Email should be provided for relaying National health alerts and medical results for patient
Patient Emergency Contact
first name
second name
last name
sex
birth date
primary telephone
secondary telephone
relationship
*Names should be english alphabets without a space
*Date of Birth should always be when the person is born, not future date or false date
*Emergency contact must provide primary telephone
*Relationship is contacts relation to the patient
*National ID will be required to be a patients emergency contact in the near future