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Dr Sankar Hospital
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Intake form
Help us serve you better
Name
*
Email address
*
What services are you interested in?
Please select at least one option.
Diabetes Management
Maternity Services
Nutrition Counseling
Prenatal Care
Postnatal Care
Diabetes Education
What is your age group?
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and above
Do you have any pre-existing medical conditions?
Please select at least one option.
None
Hypertension
Heart Disease
Kidney Disease
Thyroid Disorder
What medications are you currently taking?
Do you have any allergies?
What is your preferred method of contact?
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Phone
Email
SMS
In-person
How did you hear about us?
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Referral
Social Media
Online Search
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What is your preferred appointment time?
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Morning
Afternoon
Evening
Are you currently pregnant?
Select
Yes
No
Which service or services are you interested in?
Please select at least one option.
Diabetes management
Maternity care
Nutritional counseling
Additional questions or comments
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