Pre Registration

This is aimed at expediting the registration process when you get to the hospital. Kindly fill in all the fields to enable us complete the process at our end. You will receive a confirmation on this page if the process is successful. Give your name and contact details to the registration officer when you get to the facility.

Pre-Registration Form

First Name *

Middle Name

Last Name *

Sex *

Name of Insurance Company/ Corporate Organization/ Family

Policy Number

Date of Birth *

Marital Status *

Educational Status *

Nationality *

Phone *

Occupation *

Place of Work *

Religion *

Your traceable residential address *

Digital Address

Are you a Dependant of someone ? (Please ignore if you are paying yourself)

Dependant's First Name

Dependant's Middle Name

Dependant's Last Name

Dependant's Patient ID

Emergency Contact Person (ECP) Details

Name of Emergency Contact Person (ECP) *

Relationship with ECP *

Phone Number of ECP *

Name of Second ECP

Relationship with Second ECP

Phone Number of Second ECP

Would you like to receive messages from UGMC?* If you select yes, you will receive occasional messages from the Client & PR Department of the University of Ghana Medical Centre

Any Comments ?

Signature (Type your name) * By typing your name, you consent that the information provided in this form is correct and accurately describes you.