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Administrator, New Apollo Polyclinic

Patient Registration

Out Patient

Patient ReVisit

Registration List

Search

Clinic Referrals

Patient Registration Form
New Patient Registration
Referral
Encounter Type *

Already Generated
*
Name *

Date of Birth

No

Consultation
No

dd-mm-yyyy
Select

Mobile 2

050 

Residence Area

Gender *

Mobile 1*

Referred By

How did you hear
about us?

Select

Emirates ID

01-11-2015

Telephone
P O Box
,

Select

Registration Date *

Nationality *

050 

Visa Type

AP000030

Age *

Employer, Employee
ID
Father's Name

Reg. Number

Yrs

Months

Select

Weeks

02 

Email

Occupation
Mother's Name
Passport No.

Type *

NL 

Language Preferable

Consultation Details
Consult Date *
Doctor Name *
Insurance Details
Insurance *

Sub
Network Type

Department *

01-11-2015

----Select----

No

----Select---- 
----Select---- 

----Select---- 

Consultation Fee *

Insurance Provider

----Select---Deductible

Consultation
Lab

Card No

Radiology

Effective From

Treatment

Expiry Date

Medicine

Card No
Save

Min
For Each
For Each

AED 

Max

Co Pay

%

For All

%

For All

%
%
%