Vaccination at Rohith Physiotherapy Clinic, Nagarbhavi, Bengaluru 18.06.2021

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Fee once paid is not refundable or adjustable under any circumstances in future.

Rohith Physiotherapy Clinic, https://goo.gl/maps/FoeyVk2v73ZVv2FV6

Full Name as per Aadhar card *

Aadhar card Number *

Mobile Number *

Birth Date *

YYYY

Gender *

Male

Female

Email ID *

Address *

Are you categorized as immunocompromised (i.e. diabetic, suffering from heart, lung, or any metabolic or chronic disease, obese, pregnant, or of senior age)? *

Yes

Have you received a placebo during the COVID-19 clinical trial? *

Yes

Are you pregnant or intending to be pregnant in the next 6 months? *

Yes

Are you allergic to eggs, vaccines, or any medicine? *

Yes

Any additional information

Whatsapp Number *

Alternate Mobile Number

Payment Reference Number- Covishield Vaccine-Rs 750/- G Pay or Phonepe-9886309123 *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms