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Request for Appointment

If it is an emergency appointment, please dial 
+880 2 9896623
+88 01714090000
+88 01911555555

880 2 9891661~2  Ext:7777

Please be informed that this submission of “Request for Appointment” will only be workable after confirmation by our “Appointment Call Center”. Confirmation of Appointment depends upon the availability of doctors at your preferred date and time.

Your appointment will be confirmed through return e-mail or telephonic communication.

You must fill the * marked fields to submit your request
Title: (Mr./Mrs./Ms./Dr./Prof.)
Full Name: *
Date of Birth: *
Are you already registered with us? Yes No   *
Universal Health Identification (UHID): (If Known)
Email: ( Your Appointment Schedule will be replied through this e-mail) *
Telephone: *
Brief Description of your Problem:
Specialty:
Doctor:
Preferred Date and Time for Appointment:  
1st Preference-
Date:  
Time:  
2nd Preference-
Date:  
Time:  
Remarks:



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