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Patient Information Form – CINCINNATI CHILDREN’S HOSPITAL

Patient Information- Please provide names as they are on passport or birth certificate.
Last Name/Surname/Family Name: First/Given Name:
Nkansah Nana Akua
Middle Name: Birth Date (month/day/year): Gender:  Male ■ Female

Afra December 7 2011
Street/house/apartment:
Ablorh freeman
City: State: Postal Code: Country:
Accra Accra +233 Ghana
Home Phone (with country and city code): Cell Phone (with country and city code):
+233(0)244214779
Email:
Minaobeng35@gmail.com

Reason for Inquiry

Diagnosis:
Cerebral palsy with seizure disorder

Desirable outcome:  Treatment  Evaluation visit

How did you find out about us?

 Self  My child’s physician  Conference  Returning patient  Internet

 Other: _______________________________________

Parent/Legal Guardian 1- Please provide names as they are on passport or birth certificate.
Last Name/Surname/Family Name: First/Given Name: Middle Name:
Obeng-fobi Wilhemina
Birth Date (month/day/year): Relationship to patient:
October 1982 Mother
Home Phone (with country and city code): Cell Phone (with country and city code):
+233(0)244214779
Email:
Minaobeng35@gmail.com
Address (Please provide if it is different than patient):

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Parent/Legal Guardian 2- Please provide names as they are on passport or birth certificate.
Last Name/Surname/Family Name: First/Given Name: Middle Name:
Yeboah Nana Yaw
Birth Date (month/day/year): Relationship to patient:
22 aug 1985 Father
Home Phone (with country and city code): Cell Phone (with country and city code):
+233(0)20900896
Email:
V
Address (Please provide if it is different than patient):

Preferred spoken language: ______________________ Preferred written language: ______________________

Do the parents or guardians speak English?  Yes  No  Some
Does the patient speak English?  Yes  No  Some

Financial Information
Payment Source:  Private Insurance  Self-Pay  My government

Insurance Information
Primary Insurance: Subscriber Name: Employer Name:

Policy number: Group number: Phone number:

My child’s physician Information- Please provide if information is available

Name of primary physician (full name):Major Okyere KA
Phone number (with country and city code): Fax number (with country and city code):
+233(0)207229259
Email: Medical specialty:Pediatric specialists
Name of Institution or Private Practice:
Address:37 Military Hospital
City: State: Postal Code: Country:
Accra Accra
Name of treating or referring specialist (full name):
Phone number (with country and city code): Fax number (with country and city code):

Email: Medical specialty:

Name of Institution or Private Practice:
Address:37 Military hospital
City: State: Postal Code: Country:
Accra Accra +233 Accra

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