People In Distress

PEOPLE IN DISTRESS

ফর্মটি ইংরেজি বা বাংলায় পূরণ করুন

Initials Problems : * Coronona symptoms Fever Cardiological Orthopedic Neurological ENT Urological Gynaecological Others

If Tested COVID-19 : * COVID Positive COVID Negative Not Tested

How Long (কতদিন ধরে ভুগছেন): *

Patient's problem in brief (রোগীর সমস্যা সংক্ষেপে লিখুন) : *

Patient's Name (রোগীর নাম): *

Patient Address *

Aadhar No :

Age (years): *

Sex : *

Height : *

Weight (kg) : *

Blood Pressure :

Oxygen Saturation :

Pulse Rate (beats per minute) :

Hemoglobin :

Blood Sugar (mg/dL) :

Family Income (Rs/month) :

Medical Insurance : *

Name Of Guardian : *

Relation With Patient : *

Contact No (WhatsApp) : *

Alternative No : *

Email :

I concent to avail your consultation,advice, guidance and counseling * Yes

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