Doctor’s Prescription Submission Doctor * Doctor's Phone * Doctor's Email * Doctor's Website Patient's Details patient name * patient Gender and age * Gender & Age of Patient Appointment Date * Visited date of patient Sponsored By Sponsored by a Group or Company patient address * Postal Address of Patient patient phone * Mobile/Phone No. of Patient patient email Email of Patient Refereed By Doctor or company Chief Complaints * Main Problems of Patients Physical Examination Problems examined by doctor Provisional Diagnosis * Diagnosis of Patient Prescribed Tests * Tests for Patient's Final Diagnosis Prescribed Medication * Medicines Prescribed for Patient prescription image * Maximum file size: 2 MB Image of Prescription Upload
