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
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+960
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+977
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+687
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+234
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+1 670
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+968
+92
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+1 284
+1 340
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
Patient's Details
Patient's Full Name
*
Patient's Age
*
Years
Months
Days
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. Doctor Dental
for providing health care services to me via digital telemedicine.
STEP 2 - PROCEED TO PAY
300