Thank you for your interest. Please provide the following information about your health problems. The information that you submit will not be used or distributed for any reason other than to fulfill your request. Please note that this form is only for exchanging of medical opinion so this institution does not take any responsibility for your health since medical examinations have not been performed face-to-face. This information will enable us to route your request to the appropriate doctor. You should receive a response within 48 hours. For security reason, IP address of your device on network will be recorded on successful submission.
Your submission have been received and delivered to concerned department. You should receive a response wihtin 48 hours.