Patient Registration

OPD Registration

OPD outreach registration — field set follows the reference campaign form. Metadata-driven: edit fields or publish a new version from the admin Forms builder.

Patient Information

Patient Type *

First Name *

Last Name *

Mobile Number *

10-digit number, e.g. 98765 43210

Email (optional)

We may use this to send updates about your appointment

Date of OPD (optional)

Gender *

PIN Code *

6-digit PIN code

Speciality (optional)

Doctor (optional)

City (optional)

Problem / Reason for Visit (optional)

I agree to the hospital collecting and processing my personal details for registration, treatment and communication purposes.

Your information is encrypted in transit and handled only by the hospital.