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Thursday, July 9, 2020

Medical Information Form

Name Kiran Rao

Phone Number (+91) 990-0048451

Birth Date February 12 1994

Address Chandapura Mn Rd, , Bommasandra


Bengaluru
India

Weight: 66

Height: 181

In Case of Emergency

Name RAMANI S V

Address CHANDAPURA MN RD, BOMMASANDRA


BENGALURU
India

Home phone 973-1550379

General Medical History

Have you had the Hepatitis B No


vaccination?

Immunity information (please note: this information must be provided prior to employment or you will not
be allowed to work):

Chicken Pox (Varicella): IMMUNE

Measles: IMMUNE

Signi cant Medical History (surgery, injuries, serious illness):


NO

List any Medical Problems (asthma, seizures, headaches):


NO

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List any medication taken regularly:
NO

List any allergies:


NO

Medical Insurance Details

Do you have medical insurance? Yes

Name of Insurance Company: RELIANCE GENERAL INSURANCE

Address BENGALURU
BENGALURU
India

Policy Number: 20013581648585HPV4567

Expiry Date: 31 December 2020

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