ADMISSION QUESTIONNAIRE /QUESTIONNAIRE D'ADMISSION

Debtor's Information / Information du debiteur

Surnames /Nom
Other Names / Prenoms
Home Address / Addresse Residence
Postal address/ Address postale
Work / Employer / Emploi / Employeur
Telephone No Work / N0 de Telephone-Bureau
Telephone No Home/No de Telephone- residence
Email address
ID Number / N0 d'identite
Medical Insurance / Assurance Medicale
Insurance Number / Numero d'Assurance
Umudugudu/Village/Village
Akagari/Cell/Cellule
Umurenge/Sector/Secteur
Akarere/District/District
Intara/region/region
   

Patient Details / Details du patient


Surnames / Noms
First Names / Prenoms
D.O.B / Date de naissance
Email address
Sex /Sexe:
Male Female
Language / Langue
English/Anglais French/ Francais
ID Number / No d'identite
Religion
Next of kin / Member de Famille
Telephone No.of next of kin/No de telephone du membre de famille
Umudugudu/Village/Village
Akagari/Cell/Cellule
Umurenge/Sector/Secteur
Akarere/District/District
Intara/region/region