CASE REGISTRATION FORM

 


Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone
E-mail

Please provide the following payment information:

You can make the Payment of Consultation including Medicine Charges at my State Bank of India Branch Parbhani Account No: 11183371225. Or You can make Payment by National/International DD in favor of 'Dr. Pawan S. Chandak' payable at Parbhani.

Mode of Payment
Payment through
Payee's Name
DD/Account No.
 Date

        Please identify and describe yourself:

Date of Birth
Sex Male Female
I want to Consult for
 
Please contact me as soon as possible regarding this matter.


CLICK HERE FOR PAYMENT DETAILS

If you have any problem in filling or sending Case Record Form then Copy this form and send by email directly to us at pavanchandak498@gmail.com

or Call at +91-2452-222261, +91-9422924861 between 10 to 2 am and 5 to 9 pm at Clinic.

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