Affordable ANC & Maternity Packages – Sign Up Form

What is your first and last name?*

What phone number can we call you on?*

What is your WhatsApp number (if different)?

What county are you from?*
BaringoBometBungomaBusiaElgeyo MarakwetEmbuGarissaHoma BayIsioloKajiadoKakamegaKerichoKiambuKilifiKirinyagaKisiiKisumuKituiKwaleLaikipiaLamuMachakosMakueniManderaMeruMigoriMarsabitMombasaMurangaNairobiNakuruNandiNarokNyamiraNyandaruaNyeriSamburuSiayaTaita TavetaTana RiverTharaka NithiTrans NzoiaTurkanaUasin GishuVihigaWajirWest Pokot

How far along are you in your pregnancy?*
Not ExpectantMonth 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Month 9

What Antenatal Care (ANC) package that you are interested in?*
Cliniva ANC Package – KES 8,800Barika ANC Package – KES 9,999Shree Swaminarayan ANC Package – KES 25,000Meridian Equator Hospital ANC Package – KES 35,000LifeCare Hospitals ANC Package – KES 10,000 – KES 15,000Not interested in an ANC Package

What Maternity Delivery package that you are interested in?*
Barika Medical Centre Vaginal Delivery: KES 30,000Barika Medical Centre Cesarean Section (C/S): KES 75,000Shree Swaminarayan Hospital Vaginal Delivery: KES 65,000Shree Swaminarayan Hospital Cesarean Section (C/S): KES 125,000Meridian Equator Hospital Vaginal Delivery: KES 40,000Meridian Equator Hospital Cesarean Section (C/S): KES 150,000Ruai Family Hospital (RFH) Vaginal Delivery: KES 40,000 – KES 85,000Ruai Family Hospital (RFH) Cesarean Section (C/S): KES 100,000 – KES 140,000LifeCare Hospitals Vaginal Delivery: KES 30,000 – KES 50,000LifeCare Hospitals Cesarean Section (C/S): KES 75,000 – KES 140,000Not interested in an Maternity Package

How would you like to make payment for the ANC package?*
CashPrivate Insurance

If using private insurance, what is the insurance company?

Have you begun your Antenatal Care Clinics yet?*
YesNo

How did you learn about the Maternity Packages?

How would you like us to contact you?

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