1. Patient Information 2. Next of Kin Information 3. Payments 4. Symptoms First Name Last Name Other Names (optional) Gender Select Gender Male Female Date of Birth Marital Status Select Marital Status Single Married Widowed Divorced Separated Residence Religion Select Religion Christianity Islamic Judaism Hinduism Other Nationality Select Nationality Kenya Uganda Tanzania Phone Number Email Occupation First Name Last Name Relationship Select option Spouse Son Daughter Brother Sister Guardian Father Mother Others Residence Phone Number Email 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 ▷
