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Title:
First Name:
Last/Sur Name:
PiD No.:
Gender:
Age:
Date of Birth (YYYY-MM-DD):
Valid Mobile No.:
Alternate/Family Mobile No.:
Valid e-Mail ID:
Referred by:
Address:
C/C (Chief Complain):
H/O (History of):
O/E (on Examination):
D/X (Diagnosis):
Advice (I/X):
T/X (Treatment to be done):
Treatment Progress
R/X (Drugs/Medicines- Antibiotic):
Pain Killer (if Pain):
Gastro. (with Painkiller):
Advices/Instructions (if any):
P. Measurement 1:
D. Measurement 2:
M. Measurement 3:
Notes/Pay Instruction (if any):
Next Visit Date & Time (if any):
Date of Registration (dddd-mm-dd HH:mm:ss):
Last Updated on (dddd-mm-dd HH:mm:ss):
Bill Amount (Approx.) Tk.:
Total Paid Amount (up-to date) Tk.:
Last Pay/ Today:
Security Code (Admin Pass Code):
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