Patient’s Counter – ClinicoGlaze Healthcare

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Patient Name

Mobile No.

WhatsApp Active No.

Age

In Years

Gender

Patient's Current Health Issue

Mareez ko Takleef kya aur Kb se hae? (Chief Complaint)

Past Medical Prescriptions (if any)

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(Doctors ki Parchian)

Medical Labs/X-ray/Ultrasound/ECG (if any)

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Clinic Selection

Doctor's Selection

Filled By

Reference Code

Provide if any (Put Zero for None)

Payement Method

Your Comment & Expectations

CG Captcha

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