Client Pre-Registration

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Amref Medical Centre - Client Pre-Registration

Note: Fields Marked with (*) are Compulsory

  • Please fill in this from accurately, to enable us to serve you efficiently.

  • By completing this booking form, you are in agreement to the booking instructions on the registration form and Terms and Conditions

  • Note: Fields Marked with (*) are Compulsory
Please select Adult or Child (Under 18)
Select Service

Kindly note Yellow fever is not suitable for pregnant, breastfeeding women and people above the age of 60years.
Are you Breastfeeding?
Are you Breastfeeding?
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Personal Details of Patient

Note: Enter the Full Names of Patient as they appear on Official Documents like National ID, Passport or Birth Certificate

Please type your first name.
Please type your middle name.
Please type your last name.
Enter ID or Passport Number
Invalid email address. Please Enter only 1 email address. No spaces after email address!
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Please enter phone number eg. 722909090. No spaces, no dashes (-)
Select Date of Birth
Please select country
Select Gender
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Emergency Contact

Please type Full Name of Emergency Contact
Enter Phone Number
Select Relationship with Next of Kin

Parent / Legal Guardian Details

Please type your full name.
Enter Phone Number of Parent
Invalid email address.
ID or Passport Number of Parent / Guardian

Mode of Payment

Select Mode of Payment
Select Insurance Company
Enter Membership/Policy Number
Enter Employer
Invalid Input
Are You A Robot?
Refresh
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