Yadan Medical

34/2, Shahid Syed Nazrul Islam Sarak Hatkhola Road (Ittefaq Mor) Dhaka-1203, Bangladesh

Helpline: +8802-47110142, 01618888123, 01618886898

Website: www.yadanmedical.com | Email: yadan.medical@gmail.com

TEST APPOINTMENT FORM

(Note: The following Red marked fields are mendatory)

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Name:

Test Type:

Father Name:

Mother Name:

Mobile Number :

Passport Number :

NID Number :

Address

Sex :

Thana

District :

Date of Birth :

Email address:

Home Sample Collection Walk in Sample collection

Real Time PCR Test Fee 3500.00:

Collection Fee:1000 ( Home Sample Collection) :

Payment Mode:

Bkash Ref

Expcted Collection Date :

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