Amref Medical Centre - COVID-19 Form - Amref Medical Centre - COVID-19 Form

User Registration Form

First Name(*)

Please enter the name!

Middle Name

Please enter the name!

Last Name(*)

Please enter the name!

Username(*)

Please provide an username!

E-mail(*)

Please provide a valid e-mail!

Verify E-mail(*)

Retype the e-mail!

Password(*)

Please enter a password!

Verify Password(*)

Retype the password!

Cellphone Number(*)

Please enter phone number

Date of Birth(*)

/ / Select Date of Birth

Nationality(*)

Please select country

Gender(*)

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ID or Passport Number(*)

Enter ID or Passport Number

County of Residence

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Occupation(*)

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Emergency Contact

Full Name of Emergency Contact(*)

Please type Full Name of Emergency Contact

Phone Number of Emergency Contact(*)

Enter Phone Number

Have You Been Vaccinated against COVID?(*)

Have You Been Vaccinated?

2022 Amref Medical Centre (AMC)

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