Patients Form

Fields with * are Mandatory

Patient Name *

Age *

Gender *

Your Name (if different from patient)

Relationship with the patient

Email*

Address

Phone*

Mobile*

Country of Stay *

Nationality *

Diagnosis or Present Medical Condition *

Treatment taken so far

Present complaints

Upload Reports:

Upload Photos:

Do you want us to communicate with your local physician? If Yes, Please mention his/ her:

Name

E-mail

Intended date of Travel

When do you plan to come to India

How long can you plan to stay in India for the treatment

Do you want us to arrange for your accommodation while in India?

Number of loved ones likely to accompany the patient

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Please read the Disclaimer and the Terms and Conditions and give your acceptance.

 I have read the Disclaimer and the Terms and Conditions and I accept them.

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