Patient Registration for Online Consultation

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To be Filled by patient prior to making request for an Online Consultation with Dr Ashish Nagpal - as per State Medical Council

Email *

First Name Last Name *

Age *

Sex *

Male

Female

Other

Phone number *

Email *

Address - Number , Street , Landmark *

Address 2 City Pincode *

Any known Allergy or Systemic Disease eg: Diabetes

Emergency Contact Person - Name and Phone Number *

By Filling this Form i consent to seek & have a online medical consultation ( text / audio / video ) with Dr Ashish Nagpal on an online platform like Whatsapp , etc. I also understand that the doctor will be able to guide me medically in a limited way only due to the nature of this online consultation. I also consent to let the doctor keep data records of this online consultation as is required by the Gujarat State Medical Council. *

Yes i agree

Required

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