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 អ្នកជម្ងឺ211
Gender/យែនឌ័រMale
Family Name/ឈ្មោះគ្រួសារKIM LENG
Age/អាយុ70
Contact Phone Number/s (If any)N/A
Present Address/From:
Province/ខេត្តKampot
Kampot DistrictsAngkor Chey
Village/ភូមិN/A
Commune/ឃុំសង្កាតANGKOR JEY
Reason for visit/ហេតុអ្វីបាន ជាអ្នករាល់គ្នា នៅទីនេះនៅថ្ងៃនេះ

Pterygium | ភ្នែកឡើងបាយ
Cataract | កន្ទុយថ្លែន
Eyes Blurry Distance | មើលឆ្ងាយព្រិល
Eyes Blurry Reading | មើលជិតព្រិល
Eyes Itchy (Left) | រមាស់ភ្នែក ឆ្វេង
Eyes Tearing (Left) | ហូរទឹកភ្នែក (ឆ្វេង)
Eyes Pain/Discomfort (Left) | ឈឺភ្នែក ឬ រកាំ (ឆ្វេ
Heavy Hearing | ត្រចៀកធ្ងន់
High Blood Presure | លើសឈាម

Date20/10/2024