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Patient information


Appointment form

Home > Appointments > Begin an online request

Ready to request an appointment?
Let's begin

We will go through two short sections

Let's get started !

In "Patient information" section, we’ll gather basic information to create your medical profile.

In "Primary concern" section, we'll gather information about your patient's problems.

These details will help us begin our conversation about you and your care needs.


This should take about 5 minutes.

What is the patient's name?

What is your relationship to the patient?

Has patient previously received care at National Neuro Center ?

What is the patient's Date of Birth and Sex?

What is the patient's phone number?

What is the patient's address?

What is the e-mail ID?

What is/are the problems of the patient? 
Please be specific.

Let's sart
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