** Home Collection Request **

Paid Service :
Only 10KM 100/- Per Patient, Per Visit
> 10KM 150/- Per Patient, Per Visit
10-12 Hrs. fasting Required


Date :
Patient Name :
C/O :
Contact No. :
House / Flat No. :
Building Name :
Street / Any Landmark :
Select Area :
Email Id :
Special Request :
Verification Code
Enter Verifaction Code
 
 
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