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Personal Details
Reg. No.
Old Reg. No.
Date
First Name
Middle Name
Last Name
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Gender
Birth Date
Age
Referred Dr.
Select Type
A
B
C
Type
Select Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Blood Group
Status
Active
Contact Details
WhatsApp
Mobile No.
Email
Address
Phone No.
Pincode
City
State
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Area
Medical History
Are you allergic to penicillin or any other drugs or medicine?
Have you ever had any excessive bleeding requiring special treatment?
Have you had any other serious illness?
Are you currently pregnant?
Have you had any of the following?
Heart Problem
Jaundice
High Blood Pressure
Stroke
Diabetes
Epilepsy
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Patient from same family
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