design for learning and empowerment
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BMVSS patient information system
Name
*
First
Last
patient Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Sex
*
Male
Female
Date of birth
*
Less than 13
13-18
19-25
26-35
36-50
Over 50
enter exact date below
day/month/year
*
visit
*
first
second
third
fourth
services provided today
*
lower limb - left
lower limb - right
above knee - left
above knee - right
crutches
sewing machine
tea stall
clothes and shoes
Submit
home
laXmi
vaccination
raXsa
shakti
about us