SCTtMST

REGISTRATION DATA FORM /ae^erve/SMca QnJQOo

Name of the Patient with Initial
coocoloDjos mjvjojaa cojojo
gOCnlr^^GJ^o
Completed age Date o Birth Gender M/nJJ
DD l.)D MM YYYY
aJ}(3(ORI)lQQ>OQQ> OJCQ)Cpg eamoDRnldixwl
F/ia)j1
ST (3ia6)(S) APL /ng)nj1(^ Religion
o®(h5gl <m^ BPL/snilnJloS (ZK9)o

Monthly family income from all sources Nationality

buaplfflooro ria>^sio6nj QJO2iZ)0(ne OOODlaDCO)

Occupation /
10 (a(930}lca>j6>s/0(9^<a>d(aR}>3(in6)a3o)
(Patient's/Guardian's)
11 Name of Father/ oaoofloDjos (sraalaaooSo cnja

12 Name of Mother/saoajloD^os araizatcajos gojcS

Spouse Name edaRnooJIoaSo/eoa^oajos ooja
Single /(Qraoflaionolcs^/ad
Marital Status of the Patient 14
13
6)6)Qiai3nL£>1<a> (SldOJCnSlO Married / anajooDlao/ad

15 Name of Guardian / acBait8>d(0HJ)3Qila(^ Ooja

16 Present Address/goo^ovfixoRD oaadojlejoofUa Permanent Address/ onSidlaatoai) oeodafleioavo

House Name /ongjooJcS

House No./oJlgjoxnid

Street Name / odnojol

Place /(hilioeia

Post Office/ oaJDonJg

aoaOlonS

District/

State /(TOeonSioomo

Pin Code /nikiSoi&oaiK

RDOSaigJOS QJiS rSidKrolOaiqsjai) onSioeio nfflo# o®crtl (^)oaJ^A

ajfiBiuocaajRDloaao
I I
OaJ(S
17 ejdSoojl^oellpI
Q(DJOS OoJdl I I

O<0iOdr^OOn&iOOdO
i 1
OoJcS
Mobile.l Mobile.2
Land Line no.
Iwlth STD Code)
Phone
18
Number

PTO
19 ADHAR. No.

20 PAN oJonB.

n^cnS finJI qqcu / iiJ1(rC(<2jon5 cd>o(3aj5 mcnjd.

21
R B S Y / Chis Plus Card No.
oonsuod dai>o(3(u5 cr>(nj(3 / Ration Card No.
22 (OOcfltfOfl (fl»3d(U)lO03o ftJcQ>(8nj 6DQ(g)06)S0qje
m)(B6«;^o«B6)6ns(g)06nnf)
23 Email id

ggoonooso^o orumd^ciSiBojarD grngnj^dlgpcoa cooi / Identity proof attached herewith.

(SI$U>3d 6)€)((U}aflo(n 6)£)ej(n}a3(n5 (0)1(0£)6n)ia)S2^ <0>(ziBlfdia3 (0)1a>1^o1(D)ad cS>odcuS
24 Electoral ID
Adhar Driving Licence
I I

Whether eligible for Govt's medical Reimbursement? Yes/ No

25
ouddBOod oiaadldBsxzd o1gDeO6m^(n56>iD0^1(i5 (rnddoocooaerDO? r:-/ rj
Are you eligible for health Insurance/Claim? - to)oa9>(/3 oi^cootoj g^nstijoadorC) oJUDnnlcaJlroS
26 CHISPLUS/aS\cro<i^cni Pvt. Insurance Policy (wjtAO0^<s,cwmld9>(/3 Others/affj§§aj
ESI/§o.ng)<rS.Qn^
ID

Name, Hospital address and Email ID of the Doctor

who referred you here.
27 goQjtsoajm>«sS OnOoc^oniK (oxmoD^ ooooi&sojos
OflJ(»]o (B)^a92ai(}0>1 osiadaflejooroaijo, goexBoonod
ofleKxnxujo.

If you are a foreigner, you should attach a copy of passport and medical visa.
Passport No. Medical Visa No.
28