Akwa Ibom State Health Facility Registration

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Email address

OFFICIAL REGISTRATION FORM

Hospital / Clinic / Medical Laboratory / Mortuary / Physiotherapy Centre

10%

Licensed Officer

Personal details of the licensed officer registering the facility.

Full name

Title

Gender

Date of birth

Age

Place of birth

Nationality

Marital status

Home town

Ward

Origin & Contact

State of origin

L.G.A. of origin

Residential address

Permanent home address

Primary phone number

Second phone number

Email address

Qualifications & Professional Registration

Add one qualification, then use “Add another” where needed.

Full registration number with MDCN

Registration date

Specialty

Current practising licence / expiry date

Additional qualifications / registration

Facility Location & Proprietor

Town / Village

Ward

Facility L.G.A.

Date of initial Ministry registration

Proprietor (if different from licensed officer)

Name

Phone number

Email address

Sector

Name of employer

Address of employer

Date of engagement

Current position

Current employment details of Medical Director

Name of employer

Address of employer

Date of engagement

Current position

Sector

Constitution of Governing Body

Where applicable.

Details of Facility

Type of facility

Number of beds

No. of toilets & bathrooms

Source of water supply

Method of disposal of hazardous waste

Sources of power supply

Safety procedures in place

Fire extinguisher available Drainage available Mosquito netting available

Security provisions (burglary proof / fence etc.)

Personnel

Add staff under the appropriate cadre. Each row accepts staff name, qualification/date and employment status.

Clinical & Support Services

Medical confidentiality & privacy policy

Laboratory Services

Pharmacy / Dispensary

DDA / MDA cupboard Poisons register / drug disposal record

X-Ray Facility

Theatre — indicate available items

Emergency Preparedness — indicate available items

Delivery / Labour Room — indicate available items

Requirements & Attachments

Upload the applicable supporting documents.

Declaration

Review your entries carefully. Your backend can save drafts, validate professional registrations, and submit this form to the Ministry workflow.

I declare that the foregoing information supplied by me is, to the best of my knowledge and belief, accurate and that I accept full responsibility for consequences if any information supplied is found to be false.

Name of declarant

Date

I confirm this declaration and wish to submit the registration.