Star Medical and Diagnostic Center

SEL Trident Tower (2nd Floor), 57 Purana Palton Lane, VIP Road, Dhaka-1000

Cell: 01762696004, Tel: 008802222225001, 008802222225002

TEST APPOINTMENT FORM

(Note: The following Red marked fields are mendatory)

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Name:

Test Type:

Father Name:

Mother Name:

Mobile Number :

Passport Number :

NID Number :

Address

Sex :

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:

Bkash Ref

Expcted Collection Date :

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