ONLINE REGISTRATION FORM

FREE MEDICAL CAMP ON Diabetes Mellitus/ Madhumeha

DATE: - 14th OCTOBER 2018. SUNDAY            Time:- 8:00 am to 2:00 pm

Venue: OPD COMPLEX, M.A. PODAR AYURVED HOSPITAL, DR. ANNIE BESANT ROAD, WORLI, MUMBAI-400018.

Please Note: -

1. Please bring your previous medical reports and ongoing medicine details with you for the camp.

2. Please bring printout of this online registration form / registration confirmation email sent to you for the camp.

3. Camp time is from 8:00 am to 2:00 pm. If you are unable to select time slot (disabled), it means time slots are full then you will have to do spot registration on the day of the camp. Spot registration is free.

4. Please fill the Registration Form accurately and completely.

Sr No
Details of the person
1 Name First Name :

Middle Name :

Last name :
2 Gender   Male   Female
3 Date Of Birth
& Age
Date:

Age:     Years
4 Address
House No. / Plot No. :  
Name of the Building :  
Street / Road Name :  
Area :  
City :  
Zip Code :  
State :  
Country :  
5 Contact Details Mobile No./ Landline No. :

Email ID:

Disease History of Diabetes Mellitus
6 Year Of Diagnosis

7 Major Complaints

8 Ongoing Treatment
(Select the option applicable to you)
Select the option :



9 Already Diagnosed with Diabetic Kidney Disease?
Yes   No If Yes , Year of Diagnosis:

10 Dialysis Treatment Select the option :



11 Other Major Illness



Select Time Slot for Consultation
12
8:00 am to 8:30 am 11:00 am to 11:30 am
8:30 am to 9:00 am 11:30 am to 12:00 noon
9:00 am to 9:30 am 12:00 noon to 12:30 pm
9:30 am to 10:00 am 12:30 pm to 1:00 pm
10:00 am to 10:30 am 1:00 pm to 1:30 pm
10:30 am to 11:00 am 1:30 pm to 2:00 pm