Second opinion

Name

First Name *

Last Name *

AGE *

Gender *

Phone *

Email *

Address

Address line 1

Address line 2

City

State / Province

Postal code / Zip Code

Country

Primary Diagnosis (as per first doctor) *

Ongoing treatment/procedure done *

Current symptoms/concerns *

Upload Reports *

Upload

Drop file here or click to upload

Maximum file size allowed: 250KB

Specific Questions for Second Opinion *

Preferred way to receive opinion *

Preferred Language *

Note: Consultation is chargeable ₹ 700/- upto 5 minutes