Check Existing Patient :
Aadhaar Number:
*
Mobile Number:
Personal Information :
Full Name:
*
Mobile Number:
*
Emergency Contact Number:
*
Gender:
*
Male
Female
Age:
Date Of Birth:
(ex:MM/DD/YYYY)
E-mail:
*
City
*
Occupation:
Nationality:
*
Select Nationality
Indian
Other
Aadhar Number/Passport No:
*
Pancard Number:
*
Height:
Weight:
Vaccination certificate:
Yes
No
Marital Status:
*
Select Status
Married
Single
Aadhar Card/Passport Copy:
*
Vaccination Certificate Copy:
Note: All attachments should be either in .jpg, .png or in .pdf format. File size should not be more than 2 MB.
Booking Details :
Package Name:
*
Select Package
Treatment
Regular Package
Date Of joining:
(ex:MM/DD/YYYY)
*
Duration Of Stay:
(ex:Day:7)
*
Health Issues:
*
Blood group:
No Of Guest:
Select Accomodation (Room type):
*
Select Room Type
Premium AC
Premium Small AC
Economy AC
Economy Small AC
Guest Room
Executive Villa
Sant Villa
Management Room
Select Type
Twin Sharing
Single Occupancy
Add Screenshot Of Deposite Payment:
Note: All attachments should be either in .jpg, .png or in .pdf format. File size should not be more than 2 MB.
Other Details :
Have u undergone any surgery in last 6 months :
How's your hypertension:
Do you have Diabetes:
Any sort of any addiction Alcohol, cigarate, Tobacco, paan masala , Gutkha , Tea etc :
List of medicine on regular basis:
Do you suffer from any heart/kidney disease in past:
Yes
No
Can you walk 1 kms.:
Yes
No
Anything specific you wish us to know:
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