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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
Confirm
I agree to the
privacy & data processing
for care delivery.
Create Account
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