Sign up — Medical Desk

Full name

Phone (optional)

Password

Specialty

Professional title

Qualifications

License / PMC number

Consultation fee (USD)

City

Country

A. Patient Registration Information

1. Full Name *

2. Gender

Male Female Other

3. Date of Birth

Age (if DOB unknown)

4. CNIC / National ID (Optional)

5. Mobile / WhatsApp Number *

6. Email Address *

Account Password *

7. Residential Address

8. City

9. Emergency Contact Name

10. Emergency Contact Number

B. Type of Consultation Required

Preferred consultation mode *

Online — Video/Audio/Chat Clinic — Visit clinic/hospital Home — Doctor visits home

Preferred consultation date

Preferred time

Alternative date/time

C. Medical Specialty Required

Select the required doctor/specialist

D. Reason for Consultation

Chief Complaint / Main Health Concern

Duration of problem

Current symptoms

Have you previously consulted a doctor for this problem?

Yes No

If yes, brief details

E. Relevant Medical Information

Known medical conditions

Diabetes Hypertension Heart Disease Asthma / Respiratory Disease Kidney Disease Liver Disease None

Other condition

Current medications

Known allergies

Previous surgery/hospitalization

Relevant laboratory/imaging reports available?

Yes No

Other relevant information for the doctor

F. Upload Medical Documents

Upload only documents relevant to your consultation (PDF, JPG, PNG, DOC — max 8MB each).

Document types you are uploading

Previous prescriptions Laboratory reports X-ray / CT / MRI reports Ultrasound reports Discharge summary Other medical documents

Attach files

G. Doctor Preference

Do you have a preferred doctor?

Yes No

Preferred Doctor's Name

Preferred Gender of Doctor (Optional)

Male Female No Preference

H. Location Details for Clinic/Home Visit

Preferred clinic/hospital (for clinic consultation)

Home visit address

Area/Locality

City

Preferred visit date

Preferred time

I. Appointment & Payment Information

Consultation fee (if known)

Payment method

I understand that the appointment will be confirmed after doctor/platform availability is verified. *

J. Patient Declaration & Consent

I confirm that the information provided is accurate to the best of my knowledge. Online consultation may have limitations compared with a physical examination. Urgent or emergency conditions should use emergency medical services.

Patient/Guardian Name

Relationship to Patient (if applicable)

Date

I electronically confirm this declaration & consent. *

Patient Registration & Consultation Request

A. Patient Registration Information

B. Type of Consultation Required

C. Medical Specialty Required

D. Reason for Consultation

E. Relevant Medical Information

F. Upload Medical Documents

G. Doctor Preference

H. Location Details for Clinic/Home Visit

I. Appointment & Payment Information

J. Patient Declaration & Consent