Patient Services

View Registration

Kidly keep the following documents handy before filling out the application.

Any one Photo ID Proof (Driving License, Voter ID,Passport) in jpeg/jpg/png/bmp/pdf format – Max 2MB
Photograph (Passport size) in jpeg/jpg/png/bmp – 20 KB to 300 KB
All scanned reports in jpeg/jpg/png/bmp/pdf format – Max 2MB

TELECONSULTATION

Personal Details:

*Nationality

*Initial

*First Name

Middle Name

*Last Name

*Gender

*Date of Birth

*Whatsapp Mobile No.

Alternate Mobile No.

*Email Id

Referred by Doctor/Hospital

*Registration Location

Address:

Pemananent Address:

*Address

*Village/City/Town

*Country

*State

*District

Pincode

Correspondence Address:

*Address

*Village/City/Town

*Country

*State

*District

Pincode

Nominee Details:

Note: Nominee will be responsible for all the financial transactions in the absence of the patient.

*Nominee Name

*Nominee Relationship

* Address

* Village/City/Town

*Country

*State

*District

Pincode

*Mobile No.

Email Id

Enter the text you see above

I hereby declare that the above particulars of facts and information stated are true, correct and complete to the best of my belief and knowledge.

TELECONSULTATION

Personal Details:

Address:

Pemananent Address:

Correspondence Address:

Nominee Details:

Attendant Details:

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