Online Patient Registration

Patient Registration

Resident Type *

Select Resident Type

Title *

Select Title

Name *

Enter First Name

Enter Last Name

Gender *

Select Title

Date of Birth *

Please select a valid Date of Birth.

Aadhaar Number

Enter Valid Aadhaar Number (must be 12 digits)

Passport No. *

Enter Passport No

Valid Upto *

Select Passport Valid Upto

Address *

Enter Address

City *

Select / Enter City Name

Select this box if your city is not listed.

District *

Select / Enter District Name

State *

Select / Enter State Name

Country *

Select / Enter Country Name

Pincode *

Enter Pincode

Mobile Number *

Select Country Code

Enter Valid Mobile No (must be 10 digits)

Email Id *

Enter Email Id

Ref. Source

Select Reference Source

Ref. by

Select Referred by

I , understand that my agreement to accept OPD services is called a General Consent and that it includes any routine procedure(s) or treatment(s) such as blood drawing, physical examination, administration of medication(s), taking X-rays etc...

You must agree before register.