Diabetes Education Application Form

Patient health education has been shown by research to improve health recovery and reduced overall healthcare costs. We encourage you to apply for health education and start enjoying the benefits of this unique service offered by Mediatrix Health Services.

Surname:
Other Name:

Your Date of Birth:

Contact Phone Number:
Alternative Phone Number:

Your Email (If you have)

Your Residential Area:

Country -
County -
Sub-county/Division -

Do you have diabetes?:
If yes, what type of diabetes? : One (1)Two (2)Don't Know
Are you On Treatment? : YesNo
Are you experiencing any diabetes complications? : YesNo
If Yes, specify :
~~ The health education sessions normally take about three hours and are offered for a group of clients who have similar medical condition. A health education session is offered subject to availability of a minimum number of clients. ~~