Patient Registration Form
Clinic name: ______________________________
Date: ______________
OP No.: ______________
वैयक्तिक माहिती
Medical History / वैद्यकीय इतिहास
Tick any that apply
Jaundice / कावीळ
High Blood Pressure / उच्च रक्तदाब
Heart Diseases / हृदयरोग
Bleeding Disorders / रक्तस्त्राव विकार
Hemophilia / हिमोफिलिया
Allergy / अॅलर्जी
Anemia / अशक्तपणा (पांडुरोग)
Fits / अपस्मार (फिट्स)
Asthma / RS Disorders / दमा / श्वसनाचे विकार
Thyroid / थायरॉईड
Diabetes / मधुमेह (साखरेचा आजार)
Kidney Diseases / मूत्रपिंडाचे आजार
Pregnancy / Lactating / गरोदरपणा / स्तनपान
Consent / संमती
I hereby give consent to the doctor and those under their professional supervision to prescribe and perform whatever treatment, operation, anesthesia or other procedure which is deemed necessary or appropriate and mutually agreed upon.
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