Printable hospital template
Patient registration form for a small Nigerian hospital
Print a reception form that keeps patient identity, folder references, contact details and guardian information distinct, with guidance for uncertain details.
- Written by
- RizCare
- Published
- Last reviewed
RizCare's suggested worksheet. Adapt to your hospital. https://riz.care/library/templates/clinic-patient-registration-form
For receptionists registering new patients or checking returning records.
The next clinician needs the right person attached to the right attendance. Start registration by checking identity and looking for an existing record. This suggested administrative form helps organise those checks; clinical history and treatment decisions belong in the clinical record.
Search for an existing record before filling a new copy. A forgotten card, a changed phone number or a different spelling is a reason to check the register. None of those facts alone establishes that the person is a new patient.
Print this page or save it as a PDF from your browser. The print layout contains only the blank worksheet and its completion note. Fill it in within your hospital.
Practice: ____________________ Prepared by: ____________________ Date: ______________
| Field | Entry |
|---|---|
| Existing-record search outcome | |
| Patient full name | |
| Folder number | |
| Second identifier checked | |
| Date of birth / known or estimated | |
| Sex as recorded by hospital | |
| Contact number / whose number | |
| Address or locality, where needed | |
| Guardian or nominated contact / relationship | |
| Attendance date / destination | |
| Registered or checked by | |
| Unresolved details / action owner |
Keep completed copies with the staff authorised to use them.
How to use it
Confirm identity before assigning a folder
Ask the patient to state their name and another agreed identifying detail. WHO-hosted guidance recommends at least two identifiers, such as name and date of birth. A room number is not one of them. This is international patient-identification guidance, not a Nigerian requirement to produce a particular identity document.
Source: Patient Identification, Patient Safety Solutions, May 2007.
Keep uncertain details visible
Record the date of birth when known. If the hospital permits an estimate, label it as estimated and say what information supports it. Leave unavailable details visibly unresolved instead of inventing a date, address or phone number. Refer an uncertain record match to the hospital's designated person.
Separate the patient from the person accompanying them
For a child, the patient-name field belongs to the child. Record the accompanying adult or nominated contact and their relationship separately. A shared family phone is a contact route, not a unique patient identifier. Listing a contact does not by itself authorise disclosure of every part of the record.
Check the attendance handover
Retain the established folder number for a returning patient. Before passing the attendance onwards, check the patient reference and today's visit date. Registration should not determine whether an unwell person needs prompt care; follow the hospital's process for involving clinical staff. Keep completed forms out of view of other visitors.
What each field means
- Existing-record search
- Record whether staff found a returning record, opened a new one or escalated an uncertain match. Do not resolve two similar names by choosing the first search result.
- Full name / folder number
- Keep the patient's own name and the hospital's stable reference together. Ask for spelling, especially where a spoken name could be entered in more than one way.
- Birth date and certainty
- Distinguish a known date from an estimate. An empty field with a recorded reason is more useful than a made-up value that later staff believe was confirmed.
- Contact and relationship
- Record whose number is supplied and the relationship to the patient. A guardian or nominated contact is separate from the person receiving care, even when they pay the bill.
- Attendance and checker
- Record the visit date, the staff member checking the form and the receiving work point. Clinical information belongs in the appropriate clinical record, not this reception form.
Completed fictional example
The person, folder number and circumstances are invented. The absent phone number remains absent. This example does not imply that every patient must provide each optional detail before they can receive care.
| Field | Entry |
|---|---|
| Existing-record search outcome | Returning record found; identity checked |
| Patient full name | Fictional Patient A |
| Folder number | F-0042 |
| Second identifier checked | Date of birth, confirmed with patient |
| Date of birth / known or estimated | 12 March 1990 / known |
| Sex as recorded by hospital | Female |
| Contact number / whose number | Not supplied / contact process agreed |
| Address or locality, where needed | Fictional locality, Ibadan |
| Guardian or nominated contact / relationship | None recorded for this example |
| Attendance date / destination | 9 September 2026 / nursing station |
| Registered or checked by | Staff A |
| Unresolved details / action owner | No phone number; Staff A noted agreed contact route |
Related resources
Sources and review
The worksheet design and examples are RizCare's recommendations. The sources below support the background discussion; they do not endorse this form.
- Patient Identification, Patient Safety Solutions, May 2007 (WHO Collaborating Centre for Patient Safety Solutions). Read 9 September 2026.