Global Total
Last update on:
Cases

Deaths

Recovered

Active

Cases Today

Deaths Today

Critical

Affected Countries

Total in Kenya
Last update on:
Cases

Deaths

Recovered

Active

Cases Today

Deaths Today

Critical

Cases Per Million

[webba_booking]

PATIENT REGISTRATION FORM


    PERSONAL INFORMATION:
    *FULL NAMES:
    *GENDER:
    *AGE (In Years):
    *ID/PASSPORT NO.:
    OCCUPATION:
    *NATIONALITY:
    *COUNTY:
    *SUB-COUNTY:
    *WARD:
    *VILLAGE/ ESTATE:

    CONTACT INFORMATION:



    *PHONE NO.:
    *EMAIL ADDRESS:

    BOOKING INFORMATION:



    *REASON FOR TESTING:
    *DO YOU HAVE A TRAVEL HISTORY?
    TRAVEL HISTORY:


    *WERE YOU IN CONTACT WITH ANY CASE?:
    CONFIRMED CASE NAME:
    QUARANTINE FACILITY/ HOSPITAL/ HOME:
    *HAVE SYMPTOMS?
    *DATE OF ONSET OF SYMPTOMS:
    *SYMPTOMS SHOWN:

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