Patient Registration | Shahada Hospital

Personal Information

Passport Photo *

First Name *

Middle Name

Last Name *

Gender *

Date of Birth *

Marital Status

Contact Information

Phone Number *

Email Address *

Occupation

Nationality *

State

LGA

Residential Address *

Medical Information

Blood Group

Genotype

Status

Next of Kin

Next of Kin Name *

Relationship *

Next of Kin Phone *

Next of Kin Address

Login Details

Username * This username will be used to login.

Password *

Confirm Password *

I certify that the information provided is true and correct. I understand that my account will remain pending until approved by the hospital administration.