Patient's Name. (Please mention full name) *
Patient's Age*
Patient's Gender* Select Gender*MaleFemale
Phone Number/Mobile Number *
Email Address* Reports will be sent on this email address
Preferred date of your visit * Please note the booking of preferred date is subject to availability
Preferred time slot* Please note booking of preferred time slot is subject to availability Select Time Slot*07.30 a.m.08.00 a.m.08.30 a.m.09.00 a.m.09.30 a.m.10.00 a.m.10.30 a.m.11.00 a.m.11.30 a.m.12.00 noon12.30 p.m.01.00 p.m.01.30 p.m.02.00 p.m.02.30 p.m.03.00 p.m.03.30 p.m.04.00 p.m.04.30 p.m.05.00 p.m.05.30 p.m.06.00 p.m.
Your Address*
Please upload a scan or picture of the doctor's prescription *
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