Refer a Patient to Dr.Raj Mohan | Gynaecologist | Gynaecologic Oncologist

For Doctors:

If you are a Doctor and would like to use this web site to create a new referral for a patient, please fill out the form below:

Patient Details
Patient Name*
First Last
Title*
- Dr
- Mrs
- Ms
- Miss
Address
Date of Birth*
Phone No
Mobile*
Email
Fund Details
Reason for Referral / Nature of Problem*
Referring Doctor Details
Doctor's Name*
Speciality
Address
Phone No*
Fax No
Email*
Provider No*
Healthlink EDI
Upload File
Drop files here or

Max. file size: 100 MB.
Please upload any test results available. Maximum file size should 100MB.
Signature*
Date of Referral*