20/09/2017

Sanjay Gandhi Post Graduate Institute of Medical Sciences

Raebareli Road, Lucknow - 226 014 ,India

ONLINE REGISTRATION FORM

Reference No. REGOL-48143 Ref.Date 20-Sep-2017 Department Nephrology

Name Mr Gulab Chand

Sex MALE Marital Status

Date of Birth 17-Sep-1952 Age 65 Yrs Email

Religion Hindu Occupation Others Mobile 9415651722

Address(Permanent) Rural Address(Correspondence) Rural

House No
Street/ Village Shahganj House No
Locality/P.O Jaunpur Street/ Village Shahganj
City/ District Jaunpur District
State Uttar Pradesh Locality/P.O Jaunpur
Pin 223101
Phones City/ District Jaunpur District
Nearest Rly. Stn. Jaunpur
State Uttar Pradesh
Pin 223101

Phones
Nearest Rly. Stn. Jaunpur

Emergency Contact Guru Relationship Emergency Phone 7275211163

Ref. Doctor Ss Pandey Ref. Hospital Government Ref. Department
Hospital Jaunpur
Identity Type Adhar Card Identity No 905325859008 Issuing Authority
Please report to the online registration counter before 10.00 AM with your referral documents with this online registration
form.This is valid upto Fri Oct 20 2017 only
1. I/My patient am/is fully aware that this registration is only for O.P.D consultation and this does not qualify for
admission in Emergency Ward.
2. Report to the Reception Counter with this form duly lled along with referral documents and investigation report before
12:00 noon.
3. In all those departments where no of registration is limited,it may not possible that the patient will be seen on that day.
However ,the patient will be given next possible O.P.D appointment date.

Signature of Patient/Relative

1/1