MGM Healthcare

Followup

Called to Customer :
Yes No

Called to Customer Date : Time:

Customer Response Status:

Visa Invitation Sent :
Yes No

Patient confirm on VIL:

Payment type :

Estimate Cost :

IPS Markup(%) :

Followed By:

Treatment Plan:

Diagnosis Plan :

EncounterNo / VCID:

Department:

Doctor:

Ticket Details :

Travel Date :
Time :

Final Status :

Followup Status :

Next Followup Date:**

Appointment Date:**

Customer Comments :

Agent Comments :

Comments : (Max 180 Characters only Allowed)

Lead Assigned By / On :

Lead Received DateTime:

Centre :

Lead Type:

Main Source :

Sub Source :

Country / Code :

Category:

* Domestic * IPS

Salutation/Age:

First Name :

Last Name:

Attender Name :

Attender No:

Indian Mobile No:*

IPS M.No:

Passport No:

Passport Validate [MM/YYYY]:

STD Code:

Landline No :

Alternate M.No :

Email ID :

Type of lead :

Department:

Doctor:

Lead Severity:

Replied To Customer:

Yes No

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