Globe Health Assessment Clinic

Your Health, Our Priority

+233256109563 [email protected]

Please complete all steps to book your appointment. All fields marked with * are required.

Patient Type^*

New Patient - I don't have a folder number

Existing Patient - I have a folder number

Use your existing patient record

Patient Details

Fill in details for new patient

Given Names^*

Last Name^*

Gender^*

Date of Birth^*

0days

Phone Number^*

Email Address

Nationality^*

National ID

Residential Address^*

Optional patient details

Marital Status

Religion

Language

Occupation

Emergency Contact Name

Emergency Contact Phone

Contact Relationship

Preferred Specialty^*

Type of service required

Preferred Service

Leave blank, if you don't have a preferred service

Preferred Date

Preferred Time^*

Preferred Doctor

Select preferred doctor (optional)

Additional Notes

Any special requirements or notes