Medical Emergency Data Capture
This form is intended to record medical emergency requirements and alert the concerned team.
Note: For feedback on this initiative and/or survey, as well as to list any other service offering in this portal, please reach out to:,
Name *
Your answer
Contact number *
Your answer
Location: Latitude, Longitude ( *
Your answer
Address *
Your answer
Check the boxes below that best describes the condition of the patient according to you *
Your assessment of the situation
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