Patients Form

Fields with * are Mandatory

Patient Name *

Age *

Gender *

Your Name (if different from patient)

Relationship with the patient





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:



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

Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.

By checking this box you hereby agree to hold Indicure, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

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.

To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.