Medical Fund Application

Applicant Information

First Name *

Middle Name

Last Name *

Passport Photo

Phone Number *

ID Number

ID Copy

Relationship to Patient

Marital Status

County

Address

Patient Information

First Name *

Middle Name (Optional)

Last Name *

Marital Status

Religion

Phone Number

Date of Birth

Patient ID Number

Patient ID Copy

Medical Information

Hospital Name

Hospital Address

Medical Condition

Condition Duration

Condition Status

SHIF Number

Financial Information

Income Source

Monthly Income (KES)

Amount Requested (KES) *

Description of Need

Referee Information

First Name

Middle Name (Optional)

Last Name

Phone Number

Relationship to Applicant

Referee Document

Supporting Documents

Upload Supporting Documents (Medical Reports, Receipts, etc.) You can upload multiple files as a ZIP archive

Empowerment Fund

Education Fund

FAQ's

Medical Fund

Welfare Fund

Support Our Programs

Applicant Information

Patient Information

Medical Information

Financial Information

Referee Information

Supporting Documents

Stay Updated with
everything Zakat!

Quick Links

Contact Us

Call Us

Email Us

Address

Empowerment Fund

Education Fund

FAQ's

Medical Fund

Welfare Fund

Support Our Programs

Medical Fund

Applicant Information

Patient Information

Medical Information

Financial Information

Referee Information

Supporting Documents

Stay Updated with everything Zakat!

Quick Links

Contact Us

Call Us

Email Us

Address

Stay Updated with
everything Zakat!