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
Ntono Vivian 36 Headache, TLD Low Labs, Meds 32,000 0763814070
Dizziness,
Nausea
Namukwaya 38 UTI, TLD UnDet Labs, Meds 130,000 0705303600
Irene Abdominal
Pain
Denovensi 32 Cough, UnDet Meds, Labs 117,600 0782673068
Kyomugisha Abdominal TDF/FGTC/DTG
Pain, Ulcers
Senkooza 42 UTI,Abdomina TLD Det Meds, Labs 117,600 0705913732
Godfrey l Pain and Eye
dressing
Nabasiige 28 UTI, Typhoid, TLD Det Meds, Labs 168,000 0740273832
Joan Headache
Aliiko 30 Genita Herpes TLD Low Labs, Meds 115,000 0789171163
Benson
Nampeera 19 UTI TLD Det Labs, Meds 120,000 0701027856
Eva
TOTAL 800,200

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.