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Sample Collection / other services Request
Lab /Hospital /Dr name:
*
If you are NOT a Lab/ Hospital/ Dr, please enter 'SELF'
Patient Name:
*
Sex:
*
Please select
Male
Female
Age:
*
Address:
*
Enter the address of Lab / Hospital /Dr/ Self
Phone/Cell:
*
Email:
Referred by :
*
You must enter SELF / Dr / Hospital / Lab Name
Upload Dr /Lab requisition:
Nearest location:
*
Please select
Vijayawada, AP
Nellore, AP
Ongole, AP
Chirala, Prakasam (Dt), AP
Kavali,Nellore (Dt), AP
Gudivada,Krishna (Dt), AP
Vuyyuru,Krishna (Dt), AP
Ponnuru,Guntur (Dt), AP
Chinnaganjam,Prakasam (Dt), AP
MVPalem,Guntur (Dt), AP
* services subject to availability
Service needed:
*
Please select
Sample Collection
Test report delivery
Other services
Test/s name:
*
For multiple tests, please enter each test name followed by a comma. If this is not test request enter NONE
If requesting report delivery, enter Sneha registration ID:
*
If you do not have Registration ID or not requesting a report, Enter NONE
Describe (if other services)
Clinical history of patient:
*
If unknown/no clinical history or report delivery only please enter : NONE
Date /Time of service:
*
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Please note: for instance, to enter 6 AM, you must enter it as : 06:00 AM and NOT as 6:00 AM
If report delivery, just enter 00:00 AM
Report delivery:
*
Please select
By Email: Email entered above: No charge
By courier / post : Service charge apply
By person delivery: Service Charge apply
Self Pickup at Sneha Diagnostics center: No charge
Not applicable : other services
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