Khairul India Help Rehab Hospital & Research Centre [KIHRH&RC]

Date Of Consultation*

Name*

Date Of Birth*

Blood Group*

Marital Status*

Gender*

Age*

Height*

Weight*

Qualification*

Occupation*

Designation

Father's Name*

Mother's Name*

Husband / Guardian's Name

Permanent Address Country*

State*

City

District*

Police Station*

Post Office

Pincode*

(Area/City/Village/Street/Tahsil*)

Present Address*

Email Id*

Contact No.*

Guardian Contact No.*

Blood Pressure

Pulse / Heart Rate

Respiratory Rate

Chief Complain at on Examination*

History Of Patient*

Pathological Investigation*

Radiological Investigation*

Medicine Intake

Advice*

Under Supervision & Guidance By Dr.

Upload Pic.*

I hereby accept to abide by the present & Future rules and regulations of KIHRH&RC, A Unit Of MDDT.

"All you can do is like a farmer create the conditions under which it will begin to flourish. ? Sir Ken Robinson"