Patient Registration - KANIV Medical Camp

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Camp Location & Venue

Apollo Clinic Kuwait

Apollo Clinic. Fahaheel Express, Al Mahboula St. 115, Road 30, 54600, Kuwait.

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1. Personal Information

Full Name (English script only)

Gender

Date of Birth

Mobile Number

WhatsApp Number

Email Address (Optional)

Nationality

Civil ID Number

Company or Sponsor (Optional)

Job Title (Optional)

Address in Kuwait

Emergency Contact Name (Optional)

Emergency Contact Number (Optional)

2. Medical Info & Vitals (Optional)

Blood Group

3. Chronic Medical Conditions (Optional - Check all that apply)

Diabetes

Hypertension

Heart Disease

Asthma

Thyroid

Kidney Disease

Liver Disease

Cancer

Pregnancy

Other Medical Conditions

Patient Allergies Registry

Allergy Type

Allergen Description

No allergies added yet.

Ongoing Medications Roster

Medication Name

Dosage

Frequency

Duration

Medication Name	Dosage	Frequency	Duration	Action
No medications recorded.

Prior Surgeries

None added.

Prior Hospitalizations

None added.

Family Medical History

None added.

Smoking

Alcohol

Exercise Frequency

Sleep Duration (Hours)

4. Schedule Appointment

Select Medical Camp

Select Session Time

5. Mandatory Welfare Consents

I agree to the Privacy Consent. I authorize KANIV and partnering hospitals to process my personal details securely.

I authorize clinical staff to record, view, and analyze my health diagnostics history and vitals parameters.

I authorize on-site medical professionals to administer emergency clinical relief if deemed necessary.

Register

1. Personal Information

2. Medical Info & Vitals (Optional)

3. Chronic Medical Conditions (Optional - Check all that apply)

4. Allergies & Current Medications (Optional)

5. History & Lifestyle (Optional)

4. Schedule Appointment

5. Mandatory Welfare Consents