Add Patient

First Name: *

Last Name: *

Address:

City:

State:

Contact Number: *

Date Of Birth: *

First Name: *

Last Name: *

Relation: *

Address:

Contact Number: *

Alternate Number:

Has patient ever visited before: * Yes No

Which Symptoms is patient facing ? *

Since when patient is facing this problem?

History With Diseases

Does patient has an insaurance: * Yes No

Name Of Insaurance Company: *

Insaurance Number: *

Amount Of Insaurance:

Expiry Date: