Share your details before arriving.

Your request will appear in the hospital approval desk. An Admin or Manager verifies the patient details and assigns the consultant. The New Consultation fee stays fixed at ₹400 and your Cash/Online choice is carried into billing and the software export automatically.

For emergencies, please contact the hospital directly. This form does not create a confirmed appointment.

Patient details

Title

Patient name *Gender suggestion is optional; please confirm manually.

Mobile number *

Date of birth

Age

Gender

Father / Husband / Guardian

Address

Block

State

District

Consultation fee & payment

OPD consultation fee is fixed at ₹400.00. Please choose how you will pay. This choice will automatically go into the hospital billing/export record after staff approval.

Payment mode *

Fee amount

Visit information

The appropriate consultant will be assigned by authorized hospital staff during verification.

Referral / how did you hear about us?

Reason for visit / notes