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Packages

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Name *
Email *
Phone *
Country *
Occupation
Marital Status *
No of Children
Known Languages
Passport No
Residence No
Fax
How many persons are accompanying
Adults
Children
Interested in pleasure trip *


Medical Details
Complaints *
Diabetes *


Hypertension *


Heart Diseases *


Lung Diseases *


Kidney Diseases *


Wt *
Any long term medical treatment give details
Any surgery / Procedures before
Patient's Condition *


Type of Hospital Preferred *
Type of Rooms Preferred *
Attach copies of (In English)
Passport
Medical Report
Test Reports
Treatment Records
Laboratory Reports
Surgery Reports
FNAC Reports
Histopathology Reports
Scan Reports
Any Other Reports