** Home Collection Request **
Paid Service :
Only 5 KM
100/- Per Patient, Per Visit
> 5 KM
150/- Per Patient, Per Visit
10-12 Hrs. fasting Required
Date :
--Day--
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
--Month--
January
February
March
April
May
June
July
August
September
October
November
December
--Year--
2018
2019
2020
2021
2022
2023
2024
2025
--Preferred Collection Time--
08:00:00 AM
08:30:00 AM
09:00:00 AM
09:30:00 AM
10:00:00 AM
10:30:00 AM
11:00:00 AM
11:30:00 AM
12:00:00 PM
12:30:00 PM
01:00:00 PM
01:30:00 PM
02:00:00 PM
02:30:00 PM
03:00:00 PM
03:30:00 PM
04:00:00 PM
04:30:00 PM
05:00:00 PM
05:30:00 PM
06:00:00 PM
06:30:00 PM
07:00:00 PM
07:30:00 PM
08:00:00 PM
08:30:00 PM
Patient Name :
C/O :
Contact No. :
House / Flat No. :
Building Name :
Street / Any Landmark :
Select Area :
------Select------
A.G.office - 302005
Ajmer Road - 302006
Amba Bari - 302023
Amer - 302028
Bajaj Nagar - 302015
Bani Park - 302016
Bapu Nagar - 302015
Raja Park - 302004
Vaishali Nagar - 302021
Sanganer - 302011
Pratap Nagar - 302033
Mansarovar - 302020
Jhotwara - 302012
Jawahar Nagar,Raja ParkTilak Nagar - 302004
Malviya Nagar - 302017
C-Scheme - 302001
Email Id :
Special Request :
URL
:
Target
:
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Size
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1 ( 8 pt)
2 (10 pt)
3 (12 pt)
4 (14 pt)
5 (18 pt)
6 (24 pt)
7 (36 pt)
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