PathWel - HMS

Patient Name *

Patient Age * 36 y, 4 m, 21 d,

Date of Birth

Gender:

Male

Female

Relation With Patient*

Relation Name*

CNIC Provider*

CNIC / B-Form*

Blood Group

Provisional Diagnosis

Medical Department

Medical Conditions

Contact Number *

Address

Emergency Contact / Relation Contact

Patient Picture

Additional Comments Reference or other medical conditions

IN CASE OF EMERGENCY SELECT URGENT PROCESS

Urgent Process

Normal Process