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Create Patient Account
Care at Home
Who is filling this form?
I am the patient
I’m a relative / guardian
You can add more clinical details later in Intake.
Patient
Full name
Date of birth
Gender
Select…
male
female
other
Phone (patient)
Service address (care location)
Registrant / Relative
Full name
Relationship to patient
Mobile (primary)
Alternate phone
Email
Preferred contact
Choose…
Call
SMS
WhatsApp
Email
Address (if different)
I am the legal guardian / decision-maker
You may upload proof of guardianship later in the Intake (optional).
Account Login
Email (username)
We’ll use this to sign you in.
Password
Minimum 10 characters with uppercase, lowercase and a number.
Confirm
I agree to the
privacy & data processing
for care delivery.
Create Account
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