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Dr. Harsh Jain

Please Provide Patient Details for Appointment

Dr. Harsh Jain

Dr. Harsh Jain

Kolkata, India

Spine Surgery

Medica Superspecialty Hospital, Kolkata

Appointment Date

Name

Phone Number

Date Of Birth or Age

Country

City

Medical Issue

Thank you. Please respond to following questions for the doctor:

Dr. Harsh Jain

Dr. Harsh Jain

Kolkata, India

Spine Surgery

Medica Superspecialty Hospital, Kolkata

Brief of the medical problem *

Alternate Mobile Number Use comma ( , ) to write more than one alternate mobile number

How best do you describe the meeting with doctor? *

Consulting for the first time

I am an existing patient of the doctor. Following up on my case.

Surgery advised, looking for second opinion

Other

If doctor is not available for Consultation on the date asked by you? *

Suggest me a similar doctor and I will decide.

I will wait for the earliest possible appointment.

Other

Is patient covered under any Central or State Government Health scheme like CGHS, ECHS, etc.? *

Yes

No

I am not sure

Other

thank you

Details Received

Name:

Number:

Country:

City:

Medical Problem:

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