(To be issued on the letterhead of Smile Train Partner Hospital)

DECLARATION*

I, [insert name], parent/ legal guardian/ authorized representative of Ms./ Mr. ______________ with
patient identity number [insert ID number] (as per Hospital records), hereby inform you that, our son/
daughter/ relative has undergone surgery for Cleft Lip and Palate in this Hospital on [insert date].
In this regard, we have been comprehensively briefed about the Smile Train India project and the medical
treatment and facilities made available to us by the Hospital.
We hereby declare that, we have not paid any amount to the Hospital for the said surgery and all the
facilities have been provided to us free of cost. Further, we acknowledge and agree that Smile Train India
is not responsible or liable for any loss, liability, damage or injury related to, or arising out of, the
surgeries, or any other actions, performed by the Hospital.
This declaration is given at my own will without any pressure from any stakeholders.

Date: [insert date]

Time: [insert time] Signature of Parent/ Legal Guardian/ Authorized Representative

Patient’s Complete Address: [insert residential address]

Contact Number: [insert mobile number]
Alternate Number: [insert ID no.]

Name of Witness 1: Name of Witness 2:

Signature of Witness 1 Signature of Witness 2

[* Please provide the above information in local/ regional language also.]