Hospital Management Patient Registration Page
Personal Information
First Name
*
Middle Name
Last Name
*
Gender
*
Male
Female
Date of birth
Reason For Covid Test
Select Reason
Inbound Traveller
Outbound Traveller
Non-Traveller
Contact Information
Phone
Email
*
Address
*
City
State
Country
For Travellers Only
Passport Number
Travel Date (If Departing)
Travel Destination
Arrival Date (If Arriving)
Payment Information
Mode of Payment
*
Select your mode of payment
NITP Portal
DNA Lab Portal
Cash
Bank Transfer
If your payment is bank transfer, fill details below
Name of Account you transfered from
Name of bank you transfered from
Amount Paid in (₦)
Create Login Information
User Name
*
Password
*