Patient Inquiry Form

The following patient information form is designed for patients, physicians and family members who are considering consultation at Kothari Medical Centre or wish to seek second-opinion from a Kothari Medical Centre specialists.

If a decision is made to come to Kothari Medical Centre for consultation or treatment, this information will greatly assist us in preparing for your visit as well as you.

By completing the form below you will help us to answer your questions quickly.

NB: All patient informations will be kept strictly confidential.

Who is making this inquiry?

Purpose of enquiry:

Relationship to patient:

Patient name:

Date of birth:

Address :

Phone :

FAX :

E-mail :

Patient diagnosis/symptoms:

Are medical records available?

What type of test results or physician reports are available?

Type of Bed would like to Opt for?

Date of Appointment / Booking

 

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Kothari Medical Centre
 8/3, Alipore Road,Calcutta - 700 027
Phone: 91-33 2456-7050 -- 59
Fax: 91-33 2456 7044
E-mail: kothari9@vsnl.in