Online Registration — Kopila Pediatric Health Centre

New Patient Registration Form

Online pre-registration — fill this before your visit

Fields marked * are required. Our staff review every registration before it is added. This form does not show or access any other patient's records.

Patient

Title

Gender *

Male Female

First name *

Surname *

Known as

Date of birth *

Contact numbers

The primary number is what the clinic uses for vaccine reminder calls / WhatsApp.

Primary contact phone *

Alternate phone

Background

Insurance

Nepal Foreign Neither

Cultural & ethnic background

Nepalese Other

Country of birth

Nepal Other

If born overseas — date of arrival in Nepal

Referred by

Parents / Guardian

Mother

Title

First name

Surname

Phone *

Occupation

Address

Father

Title

First name

Surname

Phone *

Occupation

Address

Next of kin (guardian)

Same as parent / guardian above

First name

Surname

Phone

Relationship to patient

How did you hear of us?

Recommendation Passing by Other doctor Google Word of Mouth

Allergies

Any known allergies or sensitivity to drugs or dressings?

No Yes

List each drug / dressing / substance and the reaction.

Past medical history

Leave blank if none.

Surgeries

Asthma

Diabetes

Hypertension (high BP)

Other

Current medications (incl. OTC, vitamins, minerals)

Immunisations

Are immunisations up to date?

Yes No

For each, mark status. Add a date if known. (Staff confirm exact doses later.)

Vaccines already received

Optional. Add each dose already given — one line per vaccine + date.

Consent for immunisation

Kopila offers immunisation for children and adults against diseases per the CDC (USA) and EPI / WHO (Nepal) schedules. It is recommended to immunise against these life-threatening diseases.

I consent to receiving immunisation for any of the missing vaccines, and agree that Kopila may store these details to register my child and contact me about appointments. * Signature (type full name of patient / guardian)

✓

Thank you!

Your pre-registration has been sent to Kopila clinic staff for review. Please bring any vaccine records to your visit. See you soon!