Please fill the form as per the bill.

Patient Name (required)

Patient Age (required)

Patient Sex (required)
---MaleFemale
Patient Address (required)

Patient Phone (required)

Date of Sample Dropped

Email (required)

Which platform do you want your reports to be delivered? (required)
---EmailViberWhatsAppWeChat

Platform Detail (required)

Are you the patient? (required)
---YesNo

Patient Relation

Name

We will call the patient to re-confirm if this action is requested by them or not. If you have problem submitting please call 014110842

The reports will be delivered between 10 am to 5 pm