Visit Us – COCIM

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First Name

Last Name

Age

Profession

Country of Origin

Country of Residence

Phone No.

Next of Kin/Relatives Fullname

Next of Kin/Relatives Phone No.

Next of Kin/Relatives Email

Do you have any sickness?

State the nature of this sickness and all the symptoms

How long have you being experiencing this ailment?

How has it affected your daily life?

How you being hospitalised due to it? If Yes, when was this?

Are you HIV Positive?

Do you require any form of support to aid your movement such as a walking stick or wheel chair?

Are you a person living with a disability/physical challenge?

State the details of this physical challenge

Do you require any medication for any or all sicknesses listed? If YES, list the names of these medications

Are you visiting COCIM alone?

Yes

If Yes, (Enter the Name and Phone No. of the person you are coming with). If NO, write details why

I consent to have this website store my submitted information so they can respond to my inquiry