Telemedicine Consultation Form | Online Medical Consultation

Teleconsultation Request and Consent Form

Form for initiating a Telemedicine Consultation at Providence Endocrine and Diabetes Specialty Centre, Trivandrum

* Required

Thyroid Function Test
No	Tests	Amount
1	TSH	Rs 500/-
2	FREE T4
3	T3
Complete Blood Count
No	Tests	Amount
1	CBC	Rs 390/-
2	ESR
3	RBS
4	Cholesterol
Diabetic Basic
No	Tests	Amount
1	RBS	Rs 490/-
2	HbA1C	Rs 490/-
Diabetic Routine
No	Tests	Amount
1	FBS	Rs 1515/-
2	HbA1C
3	Creatinine
4	Sodium
5	Potassium
6	Lipid Profile
7	SGOT
8	SGPT
Diabetes Optimum
No	Tests	Amount
1	FBS	Rs 2160/-
2	HbA1C
3	Creatinine
4	Sodium
5	Potassium
6	Lipid Profile
7	SGOT
8	SGPT
9	Uric Acid
10	Urine Routine
11	Urine albumin: creatinine ratio
Kidney Function Test
No	Tests	Amount
1	Creatinine	Rs 500/-
2	Sodium
3	Potassium
4	Urea
5	Uric Acid
Liver Function Test
No	Tests	Amount
1	LFT	Rs 500/-
Extented Liver Function Test
No	Tests	Amount
1	LFT	Rs 800/-
2	Gamma GT	Rs 800/-
Bone Health Panel
No	Tests	Amount
1	Calcium	Rs 1895/-
2	Phosphorous
3	Alkaline Phosphatase
4	Albumin
5	Sodium
6	Potassium
7	Creatinine
8	25 OH Vitamin D
Vitamin D
No	Tests	Amount
1	Vitamin D ( 25 OH Vitamin D)	Rs 950/-
Vitamin B12
No	Tests	Amount
1	CBC	Rs 1130/-
2	Vitamin B12	Rs 1130/-
General Checkup
No	Tests	Amount
1	FBS	Rs 1385/-
2	Lipid Profile
3	Creatinine
4	Urea
5	TSH
6	SGOT
7	SGPT
8	Urine Routine
9	CBC