Covid-Booking-Form | Nairobiwesthospital

Rapid antigen (2800) RT-PCR Normal(4000) Express 1 hr rt-pcr(4000) New Patient Registration Only

ID/Passport Number(Travellers must input Passport Number below) *

First Name *

Middle Name

Last Name *

Gender*

Male Female

Date Of Birth*

Occupation*

Phone Number*

Email*

Nationality*

County*

Sub-County*

Nearest Landmark*

Estate*

Next of Kin*

Relationship*

Relationship Phone Number*

Employer Name

Employer Contact Person

Employer Contact

Reason for Testing

Type of case

Travel history

No Yes

Country Travelled

Any symptoms?

No Yes

Fever

No Yes

Cough

No Yes

Other Symptoms

No Yes

Covid19 vaccination status

No Yes

Agree with term and conditions