Personal Information Header

Last Name

This is the patients last name. Assign or change a last name by typing the desired name into the Last Name text box. *Note*

First Name

This is the patients first name. Assign or change a first name by typing the desired name into the First Name text box.

Mother's Maiden Last

This is the patients mother's maiden last name. Assign or change the mother's maiden last name by typing the desired name into the Mother's Maiden Last text box.

Mother's First Name

This is the patients mother's first name. Assign or change the mother's first name by typing the desired name into the Mother's First Name text box.

Birth Date

This is the day on which the patient was born. Assign or change the birth date by typing the desired date into the Birth Date text box using the format MM/DD/YYYY. Or, click on the calendar icon to set the date.

Please note that the system will not allow the changing of Birth Date to a date that is after existing immunizations. If such a date is entered, an error message will appear and the user will be expected to resolve the conflict with the existing immunizations via the edit immunization screen.

Middle Name

This is the patients middle name. Assign or change a middle name by typing the desired name or initial into the information field directly following 'Middle Name'.

Suffix

This is the patients' name suffix if applicable.  Assign or change the suffix by selecting one of the suffixes from the combination box directly following Suffix.

Gender

This is the patients gender. Assign or change the gender by clicking on one of the three radio buttons directly following 'Gender'. If a gender type is not selected, the system will default to 'Unknown'.

Medicaid ID

This is the patient's Medicaid identification number.

Birth Order

Only use this field for multiple births, such as twins or triplets. It is a number indicating the order in which the patient was born.

Birth Country

This is the country that the patient was born in.

Last Notice Date

This displays the last date that this patient was reported against by a provider organization. 

Last Name

The system only accepts alpha characters, dashes, apostrophes, and periods.

First Name

The system only accepts alpha characters, dashes, apostrophes, and periods.

Middle Name

The system only accepts alpha characters, dashes, apostrophes, and periods.

Mother's Maiden Last

The system only accepts alpha characters, dashes, apostrophes, and periods.

Mother's First Name

The system only accepts alpha characters, dashes, apostrophes, and periods.