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Patient Consultation Form
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Patient Consultation Form

Patient Consultation Form

by Daktari Jul 11, 2023 0 Comment

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File Size 189 KB

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Create Date July 11, 2023

Last Updated July 11, 2023

Patient Consultation Form

Download Consult-Afya patient consultation form here. Fill and send it to our professional Email or WhatsApp. Our medical experts will get to you promptly. Save long queues and overpayment of consultation fees. [__wpdm_package id='3967']

You can also fill ONLINE and send to us by clicking submit button

IDENTIFICATION DATA
First Name *
Last Name *
Phone Number *For follow-up
Residence: apartment, suite, landmark etc
City *
Country *
Email Address *
Occupation *
BIO DATA
Age *
Estimate Weight
Date *
Hours *
Minutes *
TOPICRespiratory and ChestGeneral Body SicknessGastro-Intestinal: Stomach and abdomenReproductive SystemBones, Joint & MusclesMental HealthYour Health Concern
PRESENTATION : Please Tell Us How You Feel *

Include: when did you start feeling unwell, any medication you are taking, any suspicious food or water intake, the radiation of the pain, swelling, redness and swelling, any unusual body changes.
DOCTOR'S SECTION
Is this the first incidence of the issue? *YesMore than once
Have You Taken Any Medication,NoYes
If Yes, Please Indicate Which Kinds Of Medication
Do You Have Any Medical or Family History ?NoYesI Don't Know
Have You Had Any Laboratory Test or Imaging Examination?NoYesAm Seeking One
If Yes, Please Indicate All of ThemExample Abdominal Ultra sound, Liver Function Test
Do You Wish Us To Recommend Medication, Laboratory and Imaging ExaminationYesNo
Do You Wish Our Medical Team To Reach To YouYesNo
How Do We Reach YouWhatsappSmsPhone CallEmailEnsure you have provided a working number and or Email
You May Upload Any File Here
Image, Document, Audio or Video
Enter You Preferred Mode of PaymentM-PesaAirtel MoneyBank CardPayPalThe payment quote and details will be sent to you after we have received your submission. We put your healthcare concern as first priority. Our services are much pocket friendly and hence clients/ patients are much encouraged to make submissions regardless
Consent *
I understand the usage of my data on this platform and AfyaHealthcare can use it to process my healthcare concerns through Consult-Afya feature. I also agree to pay for the services rendered in liaison to my concern submitted above.

By Submitting you agree with the privacy policy and terms and conditions.
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Daktari

Website: https://consult.afyafitness20.com

Medical Professional

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Quick Info

The telehealth platform is aimed in promoting healthcare access and provision to people on Health, Lifestyle, and Mental Health inline with Universal Health Coverage and Standard Development Goal-3.

Maximum Business Center- Nairobi
afyafitness20@gmail.com
+(254) 720-050-551

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Patient Consultation Form

Patient Consultation Form

IDENTIFICATION DATA

BIO DATA

DOCTOR'S SECTION

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