Appointment Form

Extended Health Service Online Appointment Form (विस्तारित बहिरङ्ग सेवा दर्ता फारम)

First Name (पहिलो नाम) *

Middle Name (बीचको नाम)

Last Name (थर) *

District (जिल्ला) *

Municipality/VDC (नगरपालिका/गाविस) *

Ward No (वडा नं) *

Tole (टोल) *

Phone Number (फोन नम्बर) *

Your Email Address (इ-मेल ठेगाना)

Gender (लिङ्ग) *

Nationality (राष्ट्रीयता) *

Country (देश) *

Age (उमेर) *

Appointment Date (AD) (मिति) *

Select Department (विभाग) *

Preferred Time (समय) *

Remarks [नोट] (If Any)

Note: Appointment date and time requested would be confirmed back soon.

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