Support Line : +91 7756965039
Email : dikshaahealthcare@gmail.com
Shop no.03,Kakde Shopping plaza,near Birla Ganesh statue,Pune- 410506

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Preparing for Your Test Help Ensure All Goes Smoothly.

To reduce your wait time, complete the personal information on the form in advance most routine tests.

Looking for More Info! 02 01061245741

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Registration

Please feel welcome to contact our friendly reception staff with any general or medical enquiry.

*Patient's Name:

Partent / Spouse Name:

Address:

Pin Code:

City:

Phone:

Adhar Card:

Gender: Male Female Other

Marital Status: Yes No

Date of Birth:

Anniversary:

Lab ID:

Lab Name:

*Contact Details:

Mobile:

* Pre-Existing Conditions (if any):
a. Diabetes
b. Obesity/Dietary Conditions
c. Heart / Hypertension
d. Bone & Joint related Condition

e. Respiratory Ailments / Asthama
f. Stroke / Neurological
g. Cancer
h. None as on Date

* Medication (if any):
a. Anti - Hypertensive
b. Anti - Diabetic
c. Coronary Vasodilators
d. Hormonal

e. Analgesics
f. Diuretics
g. Other (Specify) :

*Food / Other Allergy (if any):

*Hight (Approx):

Weight:

BMI:

*Doctor's Advice:

*Rx:

*Medication:

*Blood Test Advice:

*LAB Name :

*LAB ID:

*Contact Mob. No:

*E-mail:

Payment:

Rs 49 Rs 99

*Date of Payment :

*Blood Test Rusult:

*Blood Group:

*BSL (R) :

Any Other test Willing:

Yes No

* I got to know about Diksha Healthcare:
When I Walked in
Media : Newspaper
Loyalty Scheme
I was referred by a Friend / Relative/ Doctor (If referred by Docotor) Dr.
Radio

Corporate Camp
Television
Flyer/Leaflets
Clinic / Hospital
Social Media

"I hereby consent to permitting the healthcare workers of Diksha Healthcare to Clinically examine me, draw or use my blood or urine samples for tests as advised by the doctors or as per my health package selected"

By filling the Registration Form, I hereby consent/agree to receiving, in addition to test results and information related to my health, periods, updates ........... and information on promotions from Diksha Health Care, in a manner permitted by applicable law other via email, SMS or Voice Calls.

*Signature of Customer:

Signature of Customer's Substitute Decision Maker (Patient below 18 years of age):

Shop No. 3, Ground Floor, Vighnahar Hospital, Parandwadi Road, Near Pawana Hospital, Somatane Phata, Tal. Maval, Dist. Pune - 410 506. dikshaahealthcare@gmail.com 7745081543 / 7843021938

Email Id / User Name:

Password:

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Quick Contacts

If you have any questions or need help, feel free to contact with our team.

dikshaahealthcare@gmail.com
+91 7756965039

Shop no.03,Kakde Shopping plaza Above Bank of Maharashtra, Sirgaon–Somatne Road, near Birla Ganesh statue, Pune- 410506

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Working Hours

Week Days09.00 - 24:00
Saturday08:00 - 03.00
SundayDay off

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