Patient Help And Education

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AKF0

Name of the Applicant: ^*

Full Address: ^*

Dist.:

City: ^*

Pin: ^*

Contact: ^*

Religion:

Details of Patient

Patient Name: ^*

Age: ^* Years

Sex: ^*

Relation:

Aadhar: ^*

Disease: ^*

Estimate (Rs.): ^*

Income (Rs.): ^*

Hospital: ^*

Hospital Type: ^*

Passport size photo: ^*

Accept Format: jpg / png / jpeg.
Dimention should be 400px X 618px.
Max file size is less than 200kb.

Patient Signature:

Accept Format: jpg / png / jpeg.
Dimention should be 400px X 121px.
Max file size is less than 200kb.

All application must contain photo copies of the following document

Aadhar Card / Election Card: ^*

Ration Card: ^*

Estimate Letter: ^*

Electricity / Rent Receipt: ^*

Income Certificate:

Salary Certificate / Pay Slip:

For Online transfer enter NEFT Details of the hospital

Account Holder Name: ^*

Bank Name: ^*

Branch: ^*

Bank Account Number: ^*

Bank IFSC Code: ^*

Briefly mention your intention and reason for seeking the aid *

Declaration

I hereby declare that all the information given by me in the Application From is entirely true the best of my knowledge and belief.

Date: ^*

Place: ^*

Signature:

Doctor Reference & Recommendation

Name of The Doctor: ^*

Contact: ^*

Email: