Online Patient Registration

Fields marked * are required. Your details are kept confidential.

Patient Name *

Mobile Number *

Age (years) *

Gender *

Male Female Other

Email (optional)

Address *

Guardian Name (optional)

Referred By (optional)

Preferred Visit Date *

Preferred Time

Remarks / Symptoms (optional)

Once you submit the form, our front desk takes over.

Request receivedYour details are securely saved with us.
Confirmation callWe call you to confirm the visit date & doctor.
Visit & get your UHIDCarry a valid photo ID; your patient card is issued at the desk.

JANTA HOSPITAL