Title

First Name *

Middle Name

Last Name *

Gender

Date of Birth *

At least one contact method (email or phone) is required. For dependents (e.g., children), you can use parent/guardian contact info.

Email

Phone

Format: +1XXXXXXXXXX

Street Address

City

Province / State

Postal Code / ZIP

Country

Health Card Number

10-20 characters, stored encrypted

Family ID

patient.fields.allergies

Press Enter or comma to add. Click X to remove.

Referred By

Last Exam Date

Next Exam Date (Recall)

Medical Notes

General Notes

Insurance Provider

Policy Number

Hakim Platform

Add Patient