NAKI Health · Pilot 2026

Pilot Client Registration

In-home visit programme · Accra, Ghana · July 8–22, 2026

Please complete all sections. A NAKI nurse will contact you to confirm your home visit appointment. Your information is kept strictly confidential.

Personal Information

First name *

Middle name

Optional

Last name *

Age *

Phone number *

+233 XX XXX XXXX

Email address

e.g. abena@email.com

Physical address *

House number, street, area — e.g. 14 Ring Road, Osu, Accra

Referred by

Name of the person who referred you to the NAKI pilot programme

Preferred Visit Times — July 8–22, 2026

Tick one or more 1-hour slots when a NAKI nurse may visit your home. We will confirm the exact time by phone or email.

Week 1 · July 2026

Time	Wed 8 Jul	Thu 9 Jul	Fri 10 Jul
8:00 AM – 9:00 AM
9:00 AM – 10:00 AM
10:00 AM – 11:00 AM
11:00 AM – 12:00 PM
12:00 PM – 1:00 PM
1:00 PM – 2:00 PM
2:00 PM – 3:00 PM
3:00 PM – 4:00 PM
4:00 PM – 5:00 PM

Week 2 · July 2026

Time	Mon 13 Jul	Tue 14 Jul	Wed 15 Jul	Thu 16 Jul	Fri 17 Jul
8:00 AM – 9:00 AM
9:00 AM – 10:00 AM
10:00 AM – 11:00 AM
11:00 AM – 12:00 PM
12:00 PM – 1:00 PM
1:00 PM – 2:00 PM
2:00 PM – 3:00 PM
3:00 PM – 4:00 PM
4:00 PM – 5:00 PM

Week 3 · July 2026

Time	Mon 20 Jul	Tue 21 Jul	Wed 22 Jul
8:00 AM – 9:00 AM
9:00 AM – 10:00 AM
10:00 AM – 11:00 AM
11:00 AM – 12:00 PM
12:00 PM – 1:00 PM
1:00 PM – 2:00 PM
2:00 PM – 3:00 PM
3:00 PM – 4:00 PM
4:00 PM – 5:00 PM

Consent & Signature

By signing below, I confirm that the information provided is accurate and I consent to a NAKI Health nurse visiting my home during the pilot programme.

Client signature *

Sign with your mouse or finger

Date *

Print name *

I confirm the information above is accurate and I consent to a NAKI Health nurse visiting my home during the pilot programme.

NAKI Health Inc. · Accra, Ghana · nurses@nakihealth.com · Confidential