CRIMSONBOW SICKLE CELL INITIATIVE presents Project Medicate A Warrior (Intensive Medication for sickle cell Warriors 2018)
Personal/Medical Information
NAME
Your answer
AGE
Your answer
SEX
GENOTYPE (come with proof)
Your answer
PHONE
Your answer
ADDRESS
Your answer
EMAIL
Your answer
DOCTOR'S NAME
Your answer
DOCTOR'S CONTACT
Your answer
HOSPITAL (Name and Address)
Your answer
PRESCRIBED DRUG(s) Yes/No (come with prescription) *
DRUGS AND DOSAGE *
Your answer
TERMS AND CONDITIONS
Person must be available to pick up drugs monthly or quarterly from Ikeja, Lagos state. Must also come with the afore stated proof required to pick up their medications.
I consent
SIGNATURE
I, THE ABOVE NAMED INDIVIDUAL CERTIFY UPON SUBMITTING THIS FORM, THAT THE WRITTEN DRUGS ABOVE ARE PRESCRIBED BY THE DOCTOR STATED ABOVE ARE REQUIRED FOR THE IMPROVEMENT OF MY HEALTH.
I consent *
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