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Dr. Mohd. Qaleem

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Dr. Mohd. Qaleem

Dr. Mohd. Qaleem

New Delhi, India

Transplant Surgery

Fortis Escorts Heart Institute, New Delhi

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. Mohd. Qaleem

Dr. Mohd. Qaleem

New Delhi, India

Transplant Surgery

Fortis Escorts Heart Institute, New Delhi

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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