Medilane Covid Care Inquiry form

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To help the needy people during covd 19 crisis ,
Medilane's Home Health Care Service Imphal team has Started
. Covid testing ( RT-PCR ) at home
- Nursing visit for
• IV Cannulation
• Vital Check up
• Injection giving at Home
• Doctor home visit
• Tele consultation
To book the above services please fill up the following form.

Name of the service you are seeking from Medilane *

COVID Testing ( RT-PCT ) at home

Doctor home visit for Covid or non Covid patient ( mild and moderate patient only )

Nursing home visit for ( iv cannulation , Ryles tube insertion , Vital monitoring etc ) for covid or non covid patients ,

Online doctor consultation for covid or non covid patients ( mild and moderate patient only )

OXYGEN Concentrator RENTAL

Other:

Required

Name of the contact person *

Address of the patient. *

Contact number *

If covid testing at home , number of people to be test.

11 and above .

The urgency of the booking

Same day

Next Day

In 2 Days

In 3 days

If oxygen concentrator no of days for rental ?

more than 10 days.

Other:

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