Corona Positive Form

Full Name of Patient * (Required)

Full Postal Address * (Required)

Distict * (Required)

State * (Required)

Pincode * (Required)

Date of Birth * (Required)

Age * (Required)

On Which Date Corona detected * (Required)

Last Treatment Taken From Which Hospital. Please Give Full Name

Above Hospital is Government Or Private
GovernmentPrivate

How Much Amount Required for Corona Test

How Much Amount Required for Corona Treatment

Which are disease the patient already have. Please mention all the disease they have.

From how many years, they have above diseases

Name of the Doctor from which you are taking treatment for above diseases

Full address of Doctor

Full Name of Contact Person * (Required)

Contact Person WhatsApp Number* (Required)

Contact Person Mail ID * (Required)

Alternate Mobile Number

Attach Your Corona Report in PDF only

Or You can mail Corona Positive Report koronapositivedotcom@gmail.com