Patient Application Form

BUXAR HEALTH ORGANISATION

Patient Registration Form

Patient Name * :

Gender * :

Date of Birth * :

State * :

District *:

Block. *:

Panchayat. *:

Mobile No. *:

Aadhar No. *:

Address *:

Pin Code *:

Upload

Other Document

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Test * :

Blood Test * :

Membership Fee - 1000/-

Bank Detail -

Bank Name - HDFC BANK LTD
Account Holder: Buxar Health Organisation
Account No : 50100685690302
IFSC: HDFC0001652
Account Branch: BUXAR

UPI SCAN:

Payment Mode *:

Payment Receipt Upload:

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