Registration

Welcome to the Cambodia Vision Patient Registration and Digital Form Library. Below you’ll find a link to the registration form that needs to filled in. Here you can upload a photo and capture all the necessary information for other subsequent forms.

To begin the patient registration process, please fill-in the Registration Form.

Existing patients records

Below is the list of existing patients in the patient database. Please use the Patient Number when looking for their records and forms to fill out. If you need to fill out an additional form for the patient, these forms will be available after you have found your patient record on the search below.

Patient Number/ចំនួន អ្នកជម្ងឺ45
Gender/យែនឌ័រFemale
Are you pregnant/អ្នកមានផ្ទៃពោះ?no
Family Name/ឈ្មោះគ្រួសារyorn
Age/អាយុkim sreoun
Contact Phone Number/s (If any)012221980
Present Address/From:
Province/ខេត្តKampong Thom
Kampong Thom DistrictsSantuk
Village/ភូមិso yorng
Commune/ឃុំសង្កាតtang kok
Reason for visit/ហេតុអ្វីបាន ជាអ្នករាល់គ្នា នៅទីនេះនៅថ្ងៃនេះ

Pterygium |
Cataract |
Eyes Blurry Distance
Eyes Blurry Reading
Eyes Tearing (Left) |
Eyes Pain/Discomfort (Left)
heavy hearing

Date20/10/2024