BASHUNDHARA MEDICAL & DIAGNOSTIC CENTER
156, Green Majeda Park (2nd Floor), Shantinagar, Dhaka.
Helpline: 09617 222 111
COVID 19 TEST APPOINTMENT FORM
(Note: The following Red marked fields are mendatory)
Name:
Test Type:
--- Test Type ---
New
Follow Up
Father Name:
Mother Name:
Mobile Number :
Passport Number :
NID Number :
Address
Sex :
--- Sex ---
Male
Female
Prefer not to say
Thana
District :
Date of Birth :
Email address:
Home Sample Collection
Walk in Sample collection
Real Time PCR Test Fee 3500.00:
Collection Fee:1000 ( Home Sample Collection) :
Payment Mode:
--- Payment Mode ---
Cash
Bkash
Bkash Ref
Expcted Collection Date :
Ref. By:
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