PATIENT DETAILS
First Name:
Last Name:
Email_Id:
Contact No:
Date-Of-Birth:
Gender:
--Select Gender--
Male
Female
Symptom:
country Name:
--Select Country Name--
India
INDIA
INDIA
State Name:
City Name:
Area Name:
Address :
User Id :
Password :
Height :
Weight :
Major Illness :
Occupation :
