Patient Registration
Health Web Clinic
Personal Information
First Name
*
Last Name
*
Other Names
Gender
*
Select Gender
Male
Female
Date of Birth
*
Contact Information
Phone Number
*
Email Address
*
Address
Additional Information
NHIS Number
Ghana Card Number
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Relationship
Account Security
Password
*
Password must be at least 8 characters long
Confirm Password
*
I agree to the Terms and Conditions and Privacy Policy
*
Your registration will be reviewed by our team. You will receive an email and SMS notification once your account is activated.
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