Patient Registration - RAPID Rehabilitation Centre

Before you begin

This form is reviewed confidentially by our admissions team. Your progress is saved only for this browser tab and cleared after submission.

If you need urgent guidance instead of completing the form, call 0702 742 222.

Personal

Contact

Next of Kin

Employment

Medical

Insurance

Consent

Personal Details

Please provide your basic personal information

Surname

First Name

Middle Name

Date of Birth (DD/MM/YYYY)

Gender

Male

Female

Other

Nationality

County of Residence

Sub-County / Ward / Location

ID / Passport / Birth Certificate No.

KRA PIN (if applicable)

Contact Details

How can we reach you?

Phone Number

Alternative Phone Number

Email Address

Postal Address

Current Physical Address

Next of Kin / Emergency Contact

Who should we contact in case of an emergency?

Full Name

Relationship

Phone Number

Alternative Contact

Address

Employment / Occupation

Tell us about your current occupation

Occupation

Employer / Business Name

Work Address

Medical Information

This information helps us provide better care for you

Reason for Visit

Currently on medication?

Yes

If yes, specify:

Known allergies?

Yes

If yes, specify:

Known chronic conditions Please list any chronic medical conditions

Previous hospitalizations / surgeries

Insurance Information

Please provide your insurance details if applicable

SHA/NHIF Number Enter your Social Health Authority or NHIF number

Private Insurance Provider

Card / Policy Number

Principal Member Name (if not patient) If you're covered under someone else's policy, enter their name

Consent & Declaration

Please review and agree to the terms below

Patient / Guardian Name

Date

Note: After submitting this form, our admissions team will review your information confidentially and contact you to guide assessment and admission.