Oxygen Concentrator Request

Currently we are serving only Kolkata and Howrah based on availability

Current Number of available devices
Warehouse	Available Devices
Mukti (Warehouse Address)	7
RHCF (Warehouse Address)	48

Patient Information

Patient name *

Patient DOB *

Patient gender *

Patient contact no

Patient email

Patient locality / area *

Patient address *

Patient identity proof / address *

Upload patient's identity proof / address *

Choose your file...

Patient medical information

Patient's blood group *

Covid detection date *

Do you have covid-19 test report in hand? *

Upload patient's covid report (Optional)

Choose your file...

Upload patient's prescriptions (Optional)

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Upload image of patient's pulse Oxymeter (SPO2) reading*

Choose your file...

Contact person information

Name *

Email id *

Primary Mobile Number *

Alternate mobile number

Contact person identity / address proof *

Upload identity / address proof *

Choose your file...

We expect contact person will come to our designated place in Kolkata to pick up the device along with his identity proof.

Concentrator location details

Please enter the address of where the device will be placed. Address line 1*

Address line 2

Street no. and name*

Locality/area*

City*

Pincode*

Proof of address*

Please uplaod the address proof of this location

Choose your file...

You are not supposed to take the device to any other location except this above address without explicit person from HelloBeta.

I agree with the terms and conditions.

Oxygen Concentrator Request

Patient Information

Patient medical information

Contact person information

Concentrator location details

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