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Gifted Hands Medical Clinic
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Contact
Intake form
Help us serve you better
Name
*
Email address
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Phone number
*
Date of birth
Gender
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Male
Female
Preferred appointment date
Reason for visit
Do you have any chronic conditions?
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Diabetes
Hypertension
Asthma
Heart Disease
None
Current medications
Allergies
Emergency contact name
Emergency contact phone number
How did you hear about us?
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Referral
Social Media
Website
Which service or services are you interested in?
Please select at least one option.
General Consultations & Primary Care
Antenatal Care & Labor
Immunization, pediatric assessment and treatment
Pharmacy
HIV counselling and testing
Family planning (Safe motherhood)
Additional questions or comments
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