Patient registration

First name Please enter your first name

Last name Please enter your last name

Date of Birth Please enter your date of birth Please enter a valid date of birth (dd/mm/yyyy)

Gender Please select your gender

Email

Telephone Please enter your telephone number Please enter telephone with international numbering format(+234)

Password Please enter your password

Confirm password Please enter your password Password not match

Address Please enter address

State Please select a State

Area/Town Please select Area/Town

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