Date
* indicates a required field
Clinic and Encounter Details
Clinic/facility:
Date Start of Treatment:
District:
District Reg Number
Patient Referral Information
Date referred:

Referred by:
Patient Information (Edit Address using the Registration screen)
Patient address
Cell phone Number
School/Employers address
Body weight in Kgs
Height in centimeters
Treatment Supported Information
Treatment supporters Name
Relation to patient
Address
Cell Phone
Disease Classification

Others( Specify )
Patient Classification
Transfer In Information (Enter only if patient is a Transfer In)
Date Transferred In
Transferred From: (Name of Facility)
District
Date first Enrolled in TB Care