AskADoc

To be filled in by the patient/client

Ask A Doc supports clinical research. Based on this, we might utilise your de-identified data with our research partners as provided. None of this data will be used to identify you and the data will be utilised securely in a manner as per the Kenya Data Protection Act 2019. By clicking on the YES checkbox, you agree and consent to the above terms and Privacy policy. Your decision to select NO will in no way impact the quality of medical care received from us. Kindly note that in the future, you are allowed to change your decision as needed.

Yes No

Search your company name here:

First Name :

Second Name :

Surname :

Phone number using the format 07..:

Email address :

Year of birth yyyy :

Date of birth month-enter the month number not in words e.g 12 and not December:

Date of birth day :

Id number :

Locality :

Occupation :

Employment number :

Ear complaints :

Gender:

Male Female

AskADoc

Medical questionnaire

To be filled in by the patient/client