Book Appointment – Santosh Group – Santosh Hospital

Book Appointment - Santosh Group

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Patient Information

Patient Information

Please provide your personal details and medical history

First Name *

Last Name *

Date of Birth *

Gender *

Male Female Other

Phone Number *

Email Address *

Address

Medical History

Existing Medical Conditions

Diabetes Hypertension Heart Disease Asthma Arthritis None

Current Medications

Allergies

Department & Doctor Selection

Choose your preferred department and doctor

Select Department *

Cardiology

Heart & Cardiovascular Care

Neurology

Brain & Nervous System

Orthopedics

Bone & Joint Care

Pediatrics

Children's Healthcare

Oncology

Cancer Treatment

Pulmonology

Respiratory Care

Select Doctor *

Appointment Type *

Consultation

New patient consultation

Follow-up

Follow-up appointment

Emergency

Urgent medical attention

Schedule Selection

Choose your preferred date and time

Select Date *

January 2025

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Available Time Slots *

Morning

Afternoon

Evening

Estimated consultation duration: 30 minutes

Insurance Information

Provide your insurance details for coverage verification

Payment Method *

Insurance

Use insurance coverage

Self Pay

Pay directly

Insurance Provider *

Policy Number *

Group Number

Policy Holder Name

Relationship to Patient

Insurance Verification

We will verify your insurance coverage before your appointment. You may be responsible for co-pays, deductibles, or services not covered by your plan.

Self-Pay Information

Payment will be collected at the time of service. We accept cash, credit cards, and debit cards.

Confirmation Summary

Please review your appointment details before confirming

Patient Information

Name: -

Date of Birth: -

Phone: -

Email: -

Appointment Details

Department: -

Doctor: -

Type: -

Date: -

Time: -

Payment Information

Payment Method: -

Insurance Provider: -

Policy Number: -

Important Information

Please arrive 15 minutes before your appointment time
Bring a valid ID and insurance card
Bring a list of current medications
You will receive a confirmation email shortly

I agree to the Terms and Conditions and Privacy Policy. I understand that this appointment request is subject to availability and confirmation. I would like to receive appointment reminders via SMS and email.