Registration Form
Names
Family Name:
*
Given Name:
*
Middle Name:
Mother's Name:
Address
County:
Location:
Sub-location:
Village:
Phone Number:
Primary Contact Person Information
Contact Person Name:
Contact Person Phone Number:
Identifiers
AMRS Universal ID:
*
Other Identifiers:
Identifier Type
...
AMRS Medical Record Number
CCC Number
HCT ID
KENYAN NATIONAL ID NUMBER
MTCT Plus ID
MTRH Hospital Number
Old AMPATH Medical Record Number
pMTCT ID
Enter Identifier
Confirm Identifier
Sex:
*
...
Male
Female
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
How old are you in Years
*
Ethnic Group:
...
Kalenjin
Luhya
Luo
Teso
Other
Specify Ethnic group:
*
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's system-id:
*
Encounter Date
*