African Kidney Health Society

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African Kidney Health Society
Travel – Accommodation- Nutrition
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First name *

Last name *

Street address *

Phone *

Age *

Gender *

Male

Female

Other

What is your treatment date? *

What is your medical diagnosis? *

What was the date of your diagnosis? *

What treatment will you be receiving? *

Where will the treatment take place? *

What is the duration of the treatment? *

What is the frequency of the treatment? *

Will you require accommodation support? (Number of Days) *

Will you require transportation support? (Yes/No) *

Do you have a mode of transportation to your treatment? (Yes/No) – If no, how will you get to your treatment? *

Will you require nutrition support? *

"Be brave, morning will come"

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What is Kidney Disease?
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African Kidney Health Society

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