Registration Form
Names
Family Name:
*
Given Name:
*
Middle Name:
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
*
Identifiers
Medical Record Number :
*
Provider Name:
Provider's system-id:
*
Encounter Location:
*
Encounter Location
*
...
Encounter Date
*
Form UUID
*
Person Address
County:
Location:
Sub-location:
Village:
Person Attributes
Phone Number:
Mother's Name:
Race:
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