Form on Patient Info

Pattient Code

Patient Name (Value Required)

Cell No (Mobile) (Value Required)

Email (Value Required)

Date Of Birth (Value Required)

Gender (Value Required)

Gender

Male

Female

Others

Patient Referance (Value Required)

Thana/Upozila/PS (Value Required)

Post Office / Ward No

Village / Road

Occupation

Education

Fathers Name (Value Required)

Mothers Name (Value Required)

Password (Value Required)