1. Patient Information 2. Next of Kin Information 3. Payments 4. Symptoms First Name*This Field is required Last Name*This Field is required Other Names (optional) Gender*This Field is required Select Gender Male Female Date of Birth*This Field is required Marital Status*This Field is required Select Marital Status Single Married Widowed Divorced Separated Residence*This Field is required Religion*This Field is required Select Religion Christianity Islamic Judaism Hinduism Other Nationality*This Field is required Select Nationality Kenya Uganda Tanzania Phone Number*This Field is required Email*This Field is required Occupation*This Field is required First Name*This Field is required Last Name*This Field is required Relationship *This Field is required Select option Spouse Son Daughter Brother Sister Guardian Father Mother Others Residence*This Field is required Phone Number*This Field is required Email*This Field is required How will you make your payments? M-Pesa Credit Card Insurance Bank Transfer Kindly indicate if you are experiencing any symptoms below? Abdominal pain Blood in stool Fever Chest pain Dizzy Fatigue Headache Nausea Abdominal pain Blood in stool Fever Chest pain Dizzy Fatigue Headache Nausea Sweaty Thirsty Tired Weak Vomiting Headache Diarrhoea Cough Others ◁ Previous Section Next Section ▷
