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Patient Registration
Create your account and link it to your patient record
Username *
Password *
Confirm *
Full Name *
Age *
Gender *
Select your gender
Male
Female
Other
Prefer not to say
Address *
We will auto-tag “, Nueva Era” to match admin entry format.
Purok *
Select Purok
Purok 1
Purok 2
Purok 3
Purok 4
Purok 5
Purok 6
Purok 7
Contact *
Location *
Set Location
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