Patient Registration

Complete the secure form below before your visit.

Your information is stored securely. Village Health staff can read it in the protected dashboard. You will see a confirmation on this page. Reception receives an email alert without your personal details; your registration is viewed in the protected dashboard.

Patient details

First Name Last Name Date of Birth DD/MM/YYYYID Number OptionalGender

Contact and address

Street Address Address Line 2 OptionalCity Postal Code Country Phone Number Email Address

Next of kin

Next of Kin Name Next of Kin Phone Number

Medical aid

Yes, I have medical aid No, I don’t have medical aid

Notes / message Optional