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Patient Registration Form
Name
*
:
Gender
*
:
Male
Female
Other
S/O
D/O
W/O
Aadhar Number:
State
*
:
Select State
Andhra Pradesh
Uttar Pradesh
District
*
:
Mobile No.
*
:
Alternate Mobile:
Age
*
:
Select Age
18
19
Address
*
:
Disease Description
*
:
Previous Treatment:
Test Report Img 1:
Test Report Img 2:
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