YOU CAN NOW VISIT THE TESTIMONY OF JESUS INTERCESSORY MISSION VISIT US QUESTIONNAIREIf you would like to visit The Testimony of Jesus Intercessory Mission, please complete the questionnaire and submit it. Please fill out the questionnaire in detail. This will enable us to deal with your request efficiently. All further correspondence with the church regarding your visit will be done through email. Please note, you must wait for confirmation of your visit from us before making any travel arrangements. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.NAMES *FirstLastGender *MaleFemaleAge *Nationality *Country of Residence *Profession * Your Email *Phone *Relatives Name *Relatives Phone *Relatives Email *Are you having any sickness? *YesNoPlease state the nature of the problem you are having and all the symptoms. Please specify in detailFor how long have you been experiencing this problem?List all the medications you are taking/ have taken due to this problem/ conditionHow has the problem/ condition affected your daily living?Have you ever been hospitalized? If so when?If you are HIV positive, please indicate your statusHIV1HIV2HIV3*All HIV patients need to come with their most recent original printed HIV confirmatory report when their visit is confirmed. Please note that no screening report will be accepted, only a confirmatory report that clearly states that this patient is HIV I, II OR III positive, and it must be typed on the hospital's letterhead. It must be a government recognized hospital in your country. You cannot come without the correct medical report.Are you using any form of brace? *YesNoDo you experience body weakness? *YesNoAre you using any form of walking aid (crutch, stick, etc.) or wheelchair? *YesNoAre you using any medical device to support your health condition? *YesNoAre you limping? *YesNoDo you still go about your daily activities normally without using any aids or assistance from other people? *YesNoCan you walk normally/ climb stairs without assistance? *YesNoHave you had any surgery or other therapy as a result of the problem/ condition? If so, please give details.Is any part of your body swollen? If so, where?Do you have any open wound? If so, where?Are you on a special diet as a result of your sickness/ problem? If so, please state detailsDo you have any other sickness or problems. If so, please list all symptoms, treatments and medicationsDo you intend to come alone or accompanied? (If you will be accompanied, please ask each of those with you to also submit this questionnaire, indicating in the comments section that they intend to come with you) *AloneAccompaniedCommentsSubmit Questionnaire KINDLY WAIT For confirmation from us before making any travel arrangements and/or book any flights tickets. Please call us on this line and wait for confirmation before coming: Call us: +234 810 573 8475 (WHATSAPP ONLY) FOR ANY INQUIRIES Contact Form DemoFirst NameLast NameEmailSubjectYour MessageSubmit Form