Step 1
Who is the patient?
Me
Family Member
Contact Details
Patient's Mobile Number
*
+91
+972
+93
+355
+213
+1 684
+376
+244
+1 264
+1268
+54
+374
+297
+61
+43
+994
+1 242
+973
+880
+1 246
+375
+32
+501
+229
+1 441
+975
+387
+267
+55
+246
+359
+226
+257
+855
+237
+1
+238
+ 345
+236
+235
+56
+86
+61
+57
+269
+242
+682
+506
+385
+53
+537
+420
+45
+253
+1 767
+1 849
+593
+20
+503
+240
+291
+372
+251
+298
+679
+358
+33
+594
+689
+241
+220
+995
+49
+233
+350
+30
+299
+1 473
+590
+1 671
+502
+224
+245
+595
+509
+504
+36
+354
+91
+62
+964
+353
+972
+39
+1 876
+81
+962
+7 7
+254
+686
+965
+996
+371
+961
+266
+231
+423
+370
+352
+261
+265
+60
+960
+223
+356
+692
+596
+222
+230
+262
+52
+377
+976
+382
+1664
+212
+95
+264
+674
+977
+31
+599
+687
+64
+505
+227
+234
+683
+672
+1 670
+47
+968
+92
+680
+507
+675
+595
+51
+63
+48
+351
+1 939
+974
+40
+250
+685
+378
+966
+221
+381
+248
+232
+65
+421
+386
+677
+27
+500
+34
+94
+249
+597
+268
+46
+41
+992
+66
+228
+690
+676
+1 868
+216
+90
+993
+1 649
+688
+256
+380
+971
+44
+1
+598
+998
+678
+681
+967
+260
+263
+591
+673
+61
+243
+225
+500
+44
+379
+852
+98
+44
+44
+850
+82
+856
+218
+853
+389
+691
+373
+258
+970
+872
+262
+7
+590
+290
+1 869
+1 758
+590
+508
+1 784
+239
+252
+47
+963
+886
+255
+670
+58
+84
+1 284
+1 340
Please fill in Mobile Number
Please fill in valid 10 digit mobile no
Would you like doctor to
Video Call
you over Whatsapp on
Yes
No,
Whatsapp Number is different
Whatsapp Number for Video Call
*
+91
+972
+93
+355
+213
+1 684
+376
+244
+1 264
+1268
+54
+374
+297
+61
+43
+994
+1 242
+973
+880
+1 246
+375
+32
+501
+229
+1 441
+975
+387
+267
+55
+246
+359
+226
+257
+855
+237
+1
+238
+ 345
+236
+235
+56
+86
+61
+57
+269
+242
+682
+506
+385
+53
+537
+420
+45
+253
+1 767
+1 849
+593
+20
+503
+240
+291
+372
+251
+298
+679
+358
+33
+594
+689
+241
+220
+995
+49
+233
+350
+30
+299
+1 473
+590
+1 671
+502
+224
+245
+595
+509
+504
+36
+354
+91
+62
+964
+353
+972
+39
+1 876
+81
+962
+7 7
+254
+686
+965
+996
+371
+961
+266
+231
+423
+370
+352
+261
+265
+60
+960
+223
+356
+692
+596
+222
+230
+262
+52
+377
+976
+382
+1664
+212
+95
+264
+674
+977
+31
+599
+687
+64
+505
+227
+234
+683
+672
+1 670
+47
+968
+92
+680
+507
+675
+595
+51
+63
+48
+351
+1 939
+974
+40
+250
+685
+378
+966
+221
+381
+248
+232
+65
+421
+386
+677
+27
+500
+34
+94
+249
+597
+268
+46
+41
+992
+66
+228
+690
+676
+1 868
+216
+90
+993
+1 649
+688
+256
+380
+971
+44
+1
+598
+998
+678
+681
+967
+260
+263
+591
+673
+61
+243
+225
+500
+44
+379
+852
+98
+44
+44
+850
+82
+856
+218
+853
+389
+691
+373
+258
+970
+872
+262
+7
+590
+290
+1 869
+1 758
+590
+508
+1 784
+239
+252
+47
+963
+886
+255
+670
+58
+84
+1 284
+1 340
Please fill in valid mobile no
Patient's Details
Patient's Full Name
*
Please fill in full name
Patient's Age
*
Years
Months
Days
Please fill in Age
Please fill in valid age
Patient's Gender
Male
Female
Other
I understand that telemedicine is the use of electronic information and communication technologies by healthcare professionals and hereby consent to
Dr. Lalit Kumar S
for providing health care services to me via digital telemedicine.
Please accept the terms.
STEP 2 - PROCEED TO PAY
300