Virtual OPD Form
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Name *
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Email *
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Mobile *
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Profession *
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Age *
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Address *
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Weight: *
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Height: *
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Do you smoke
Do you consume alcohol
Allergies (Food)
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Are you *
Medical condition(s)/Disease(s) *
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Name of the Medications taken along with dosage: *
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For how long have you been taking this/these medicine(s) *
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Any discomfort /unusual feeling or any other important information that is not mentioned in the form which you would like to bring to our notice:
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NOTE: Please attach all the relevant reports (latest) related with your medical condition(s) and also mention the name of the medications clearly along with the dosage taken.
Your 4 questions for Dr. Biswaroop Roy Chowdhury? Please avoid writing lengthy questions.
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