Patient online consultation form
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Your Name *
Date *
MM
/
DD
/
YYYY
Email Address
Age *
Address
Contact number (mobile) *
COVID Positive *
Chief complaints *
Please  write  Ex. Fever, Cough, Shortness of breath, Headache, Anxiety, Stress, Others
How many days/weeks/months earlier you were completely well? *
(Please write days, weeks or months)
Preferred time for consultation *
Preferred doctor for consultation
(Please chose  doctors name from website www.telemedicinenepal.com)
Have you taken consultation from our website any time previously for any other problem? *
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