INTERNATIONAL MEDICAL COLLEGE & HOSPITAL
Excellence in Medical Education & Healthcare
IMCH HOME
Covid-19 Appointment Form
Fields with
*
are required.
Patient Full Name (As per NID/Passport)
*
Age
*
Gender
*
--- Select an option ---
Male
Female
Other
Address
*
Upazila/Thana
*
District
*
Mobile No
*
Phone No
Patient Type
*
General
Corporate
IMCH Staff/Student
Company Name (If corporate client)
Email
NID/Birth Certificate/Passport No.
Preferred Date of Examination
Remarks/Comments