Insurance details form.

Please submit your insurance details to initiate the pre-authorization process for your virtual consultation through Pigia-Penda visit. We shall get back to you as soon as we receive word from your insurance.

Patient's Name

First Name

Last Name

Insurance?

What insurance are you covered with

Insurance member number

Enter your Insurance member number.

National ID

Enter your national ID number

Phone Number

Please enter your phone number here EX. 254724298442

Preferred Consultation Date

YYYY

Preferred Consultation Time

Hour

Minute

Second

Upload a copy of your insurnace card

FileField; Maxsize=10000kb; Multiple

Insurance details form.

Medical Centre hours