Medical Tourism - Form
   
Where are you from
   
Nationality
   
Is this Regarding you / relative
   
Your Name
   
Your Email *
   
Patient's Name *
   
Patient's DOB *
   
Gender Male      Female
   
Complaints
   
Attach Medical Files, if you have any
   
Likely time of visit
   
Location you prefer
   
Referal Doctor
   
Letter of Invitation for Medical Visa
   
Passport No
   
Security Code *
 
       
Contact Us:

Dr. Agarwal's Eye Hospital

Address: 4A, Prince Arcade, 22-A, Cathedral Road,
Chennai - 600 086,
INDIA

Tel: +91 44 4314 1205
Fax: +91 44 4299 7745
E-Mail: dragarwal@vsnl.com