Appointment Form

Thanks for registering. Please fill the form below to fix the appointment.
पंजीकरण के लिए धन्यवाद, कृपया नीचे दिया गया फ़ॉर्म भरें।

Name of patient:
Age:
Wt (Actual or approximate):
Address:
Mobile No.:
E-mail ID:
Appointment Type:
Consultation with:
Hospital identification No. (For follow up patients)-

Online consultation has limitations and is not a substitute of physical visit. Avoid Travel during corona pandemic .Please tick below for consent of online consultation.
I Give consent for online consultation of my patient. I am aware of limitations of online consultation. Hospital may refuse / discontinue / Refer / ask for physical visit at any time during consultation process. I am also aware that Consultation will be provided by hospital at specified given time only.