Patient’s Name *

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Please enter patient name.

Co-patient’s name if accompanied

(Submit a separate application)

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Please enter co-patient name.

Father’s Name *

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Please enter father's name.

Date of Birth *

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Please enter date of birth.

Marital Status *

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Please enter marital status.

Full Postal Address *

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Please enter full postal address.

Telephone/Mobile *

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Please enter phone number.

Local Contact Person *

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Please enter local contact person.

Telephone *

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Please enter telephone number.

Occupation *

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Please enter occupation.

Country *

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Please select a department.

Nationality *

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Please enter nationality.

For Foreign Nationals/Non Resident Indian/OCI/PIO

Passport No

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Please enter passport no.

Date of issue

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Please enter date of issue.

Place of issue

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Please enter place of issue.

Mandatory as per Immigration Rule:

Domestic patients must present their Photo ID in Original, without which admission may be denied.

Number of Days Stay Desired

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Please enter number of days stay desired.

Details of Reservation Deposit

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Please enter details of reservation deposit.

In case of re-admission, please write

Previous Date of Admission

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Please enter previous date of admission.

UHID Number

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Please enter uhid number.

Accommodation

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Please enter accommodation.

Personal History: (Please give Specific information) All particular should be filled in.

Height (in cm)

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Please enter height.

Weight (in Kg)

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Please enter weight.

Urination

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Please enter urination.

Menstrual cycle

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Please enter menstrual cycle.

Disease Details

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Please enter disease details.

Duration of Disease

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Please enter duration of disease.

Please answer the following

Have you undergone any surgery within 6 months?

Yes

Give Details

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Please enter duration of disease.

Do you suffer for any type of Hernia?

Yes

Give Details

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Please enter duration of disease.

Do you suffer from any kind of skin disease?

Yes

Give Details

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Please enter duration of disease.

Have you suffered from Heart ailment or undergone Anioplasty / Bypass surgery in the past?

Yes

Give Details

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Please enter duration of disease.

Have you suffered or suffering from any type of Kidney disease?

Yes

What medicines are you taking at present?

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Please enter medicines.

Are you addicted to any substance?

Tea

Coffee

Smoking

Alcohol

Drug Addiction

Zarda

Panmasala

Can you walk 1 km without any support?

Yes

Give Details

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Please enter duration of disease.

Are you vaccinated?

1st dose

2nd dose

Not vaccinated

Mention the vaccinated date *

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Please enter vaccinated date.

Are you physically /visually disabled in any way?

Yes

Give Details

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Please enter details.

Are you suffering from any kind of Allergy?

Yes

Application for Admission

Personal Details

For Foreign Nationals/Non Resident Indian/OCI/PIO

In case of re-admission, please write

Personal History: (Please give Specific information) All particular should be filled in.

Please answer the following