Patient Details

Name *

Age *

Gender *

Mobile Number *

Alternate Mobile Number

Email Id *

Occupation *

Address & house no *

Building / Apartment *

Area *

City *

Camp *

Ward No *

Pincode *

Test Done ? *

Care Taker Name *

Care Taker Age

Care Taker Gender

Care Taker Mobile *

Care Taker Address

Upload Self Declaration Form * (Upload jpg, jpeg, png, gif file) Download Self Declaration Form

Doctor Name *

Doctor Contact Number *

Clinic / Hospital Address *

Doctor Declartion upload * (Upload jpg, jpeg, png, gif file)

Terms & Conditions as per minister of H & F welfare , GOI dated 2nd july 2020