MEF REQUISITION TOOL.

REGION: KAMPALA
CENTER NAME: VICTORY

CLIENTS AGE DIAGNOSIS REGIMEN VIRAL MEF BEING AMOUNT CLIENTS

NAME LOAD REQUESTED CONTACTS.
i.e. Labs,
Xray, Meds
Kabali 30 Swelling of TLD Undet Labs, Meds, 135,000 No Number
JohnBosco the penis medical
sundries
Christopher 25 Bacteramia, TLD Undet Labs, Meds, 192,000 0703612023
Mwesigye Cellulitis and Dental
Dental
Arinaitwe 20 Kisipi - TLD HVL Meds, 140,000 No Number
Leilah Spurdict Medical
sundries
Nakazibwe 37 Malaria/Fever TLD Undet Meds, Labs 36,000 No Number
Rosemary
Nakato 44 Toothache TLD Undet Meds, Dental 47,000 0789171163
Deborah
Nakachwa 40 Malaria, TLD Undet Meds, Labs 80,000 No Number
Ruth Headache,
joint pains,
body
weakness
Nabasiige 28 New Mother TLD Det Food 54,000 0704350893
Joan Supplements
Transport 16,000

Total MEF 700,000

Recieved

N/B

- Requests should be sent in immediately they are received. Clients should bring in their
requests as soon as received within 2 days. Encourage them to do so.
- All liquidations should be sent in by Friday
- All liquidations should include the prescription and the receipts and attach the liquidation
forms and receipts together.