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name
*
mail
*
phone number
*
date of appointment
*
Specialization
Cardiology
Heart Surgery
Skin Care
Body Check-up
Numerology
Diagnosis
Others
Choose Hospital
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Hospital 5
gender
*
gender
Male
Female
symptoms
*
Taking any medications currently?
Yes
No
If yes,Please list it.