Patient Intake Form

Share the patient's details and health history before a consultation, so the doctor can prepare. If you need help, call the Betser support team on +91 9495 866 100.

Call Us when you Need Help!

Care Manager: +91 9495 866 100

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Patient Intake Form

If you can't fill in the form, the Betser support team will help you fill it in with the patient's consent, along with a call back from the team.

If you are not the patient and are consulting for family or friends, please make sure you have the patient's consent, share the correct details on the patient's behalf and tell us your relationship with the patient. The information you give helps the doctor towards a better health outcome.

If you are consulting for a minor (under 18), please share a parent's contact details and their consent.

Your answers are confidential and stored securely. See our Privacy Policy. Questions marked * are required.

Personal information of the patient

Full name of the patient *

Age of the patient *

Gender *

Height *e.g. 165 cm or 5 ft 5 in

Weight *e.g. 62 kg

Address *

City *

State *

Country *

PIN / postal code *

Phone number of the patient *

Present location of the patient *Where the patient is now, if different from the address.

Email address of the patient *

Information about the person booking

The person consulting with Betser Life for family or friends, or the emergency contact who will accompany the patient to an in-person consultation.

Are you the patient? *

Yes, I am the patient No, I am booking for someone else

Your full name *

Relationship with the patient *

Your phone number *

Health information of the patient

Regular medication(s) and dosages, if any *Write None if there are none.

Allergies (food, medication, others), if any *Write None if there are none.

Is the patient currently under any medical treatment? *

Yes No

Please describe the reason for your consultation *

Current symptoms *The main concern or symptoms the patient is facing right now.

Duration of these symptoms *How long the symptoms have lasted helps the doctor diagnose.

Medical history *Previous illnesses and how long the patient has had them.

Past surgeries or hospital stays *With dates and reasons if available. Write None if there are none.

Family medical history *e.g. heart disease, diabetes, high BP, cancer.

Department / specialty preference

Do you know which department's doctor you would like to see? *

Yes, I know which department No, I'm unsure and would appreciate guidance

The doctor you have chosen from Betser Life's doctors, if any

Do you want a call back from the Betser support team? *

Yes No

Medical reports (if available)

Blood tests, imaging reports (X-rays, MRIs…), prescriptions currently taken, previous discharge summaries. You can attach them here.

Describe the reports you are sharing

Anything else you would like the doctor to know

Attach reportsPDFs or photos, up to 10 files of 15 MB each.

Consent and acknowledgment

I hereby provide consent for treatment and agree to the collection and use of my personal and health information for medical care. I understand that this information is confidential and will be stored securely. *

Full name of the person filling in this form (the patient, or the authorised person consulting on the patient's behalf with their or their family's consent) *

Telephone Support

Call us Mon. – Sat., 9 am – 7 pm IST and our representatives will help you make an appointment that’s convenient for you.

Call Support: +91 9495 866 100

Virtual Visits

You can have your appointment without leaving your home. It’s the easiest way to get the care you need to stay healthy.

Book An Appointment

Make an appointment with us at the nearest facility to directly examine your health.

Book An Appointment