REGISTRATION FORM
NAME OF PATIENT
(Required)
NAME OF PATIENT
First
DIAGNOSIS
(Required)
DIAGNOSIS
First
age
(Required)
AGE/SEX
Untitled
(Required)
ADDRESS
Number
(Required)
PIN CODE
Untitled
CITY/STATE
Phone
(Required)
WHATSAPP NO.
Email
(Required)
EMAIL
Number
PAYABLE AMOUNT
Please select your mode of consultation:
(Required)
Please select your mode of consultation:
Emergency video consultation (with a waiting period of 4-5 days)= 5000/-
Emergency physical appointment (with a waiting of 4-5 days) = 5000/-
Routine slot video consultation (with a waiting of 7-8 working days) = 1500/-
Routine slot physical appointment (with a waiting of 7-8 working days) = 1500/-
Scroll to Top
Call Now Button
