तारांकन चिह्न से चिह्नित सभी फ़ील्ड * अनिवार्य हैं

Mobile Verification

Please enter a valid mobile no.
Please click on Get OTP link to receive a 6 digit long OTP on your mobile, enter that OTP here

I. रोगी का विवरण

Please select whether you are a patient or somebody else is a patient
First name must not exceed 50 characters length
Last name must not exceed 50 characters length
Please enter initials
If you know date of birth then please select date of birth or else select age
Please select date of birth
Please enter age
Please select age unit
Please select gender
kg
Address can not exceed 1000 characters in length
Please enter a valid pin code
Please select district
Please select state
Please select country
Please select how do you know the patient?
Please enter relation of family member, must not exceed 50 characters length
Please enter others, must not exceed 50 characters length

II. दुष्प्रभाव का विवरण

Please select started date
Please enter others, must not exceed 60 characters length
Please select IPD/ OPD
Please enetr IPD/ OPD no., must not exceed 20 characters length
Please enter hospital name, must not exceed 100 characters length
Please enter address, must not exceed 150 characters length
Please describe the details of side effect, must not exceed 5000 characters length
Please enter others, must not exceed 60 characters length
Please select date of return
Please enter location, must not exceed 60 characters length
Other relevant information must not exceed 2500 characters length

III. चिकित्सीय उपकरण का विवरण

Please enter device name, must not exceed 100 characters length
Please enter model no., must not exceed 50 characters length
Please enter serial no., must not exceed 50 characters length
Please enter batch/ lot no., must not exceed 50 characters length
Please enter software version, must not exceed 50 characters length
Please select manufacture date
Please select installation date
Please select expiry date
Please select implantation date
Please eneter device manufacturer name, must not exceed 60 characters length
Please eneter local supplier name, must not exceed 60 characters length

IV. प्रासंगिक दस्तावेज़(दस्तावेजों) को अपलोड करें

Document title can not exceed 60 characters in length. Also, this becomes a required field if document upload field is populated
Upload document file can be of PDF/JPG/MP4 type, and can not exceed 10 MB in size. Also, this becomes a required field if document title field is populated