CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PARTA

HH
HERITAGEHEALTH
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be laken as an admission of liability

IRDAI License No. 008

DETAILS OF PRIMARY INSURED: (To be filled in block letters)

a) Policy No: 2 5 I 1 o o s o E 1 o ooT 8 b)SI No Cnlicato Nlo I

C) CompanyTPA ID
No:HHS.lol7oo|6|7||o|33 |U
d)Name
ANOS KOMARLD
e) Address
lo ROMoRE ToAERS RAmESHCAR TEMPLE
MlAlR NIAARVASDAAA
HAA AaAR VAoDa R[A
State: ARATLLIUH
Pin Code:3aloo 2 3 Phone No S 8 2 z 1 3 E m a l 1D: monbonksorr g m a i l : a y
DETAILS OFINSURANCE HISTORY:
a) Currently covered by any other Mediclaim/Health insurance: Yes Noo b) Date of commencement of first insurance without break

c) If yes. company name

Polley No I
Sum Insured (Rs.) d) Have you been hospitalized in the last four years since inception ofthe contract? LJYes LLUNo Date
Diagnosis e) Previously covered by any other Mediclaim/Health lnsurance:Yes

li yes. Company Name

DETAILS OF INSURED PERSON HOSPITALIZED:
a. Name
d) Date of Birth 2 6|8|6
b) Gende Male Female1 c)Age: Years 3 Months MM
e) Relationship to PrimaryInsured: SelfSpouse ChildFather Mother Other (Please Specify).
Occupation: Service SelfEmployedHomemakerStudent Retired OtherPlease Specity),
9)Address (if diferent fram above): SAMEH.

City: State

Pin Code: Phone No LEmail 1D

DETAILS OF HOSPITALIZATION:
a) Name of Hospial vhere Admited NIAMEETLo MEN RDSPiTAL HL
b) Room Category occupied Daycare Single occupancyU Twin sharing 3 o r more beds perroom
d) Date ofinjury/Date Disease irst detected/Date of Delivery 2 s l o 2 l a
C) Hospilatization due to :
Injury lness Materniy 9) Data of Discharge:26MS 2NJ h) Time:24s
e) Date of Addmission Time:]lo|o]
RoadTraffic AccidentSubstanceAbude iAlooholConsumption Medico legat:YesNo
i) If injury give cause : Self inflicted
i) MLC Report&Police FIR attached YesNo )system of Medicine
i) Reported to police LYesNo
DETAILS OF CLAIM

a) Details of the treatment expenses claimed Claim Documents Submitted Check List
i. Pre-Hospitalization Expernses: Rs. L26 o i. Hospitalization Expenses : Rs. 3s|lz Claim Form Duly signed
ii.Post-Hospitalization Expenses Rs. ulsb] iv. Health-Check up Cos Rs. Copy of the claim intimation, if any

v. Ambulance Charges Rs. vi. Others (code): Rs. Hospital Main 8ill

Total
R 62l21z Hospital Break-up Bill

vii. Pre-Hospitalization period Daya D vit. Post-Hospitalization period : Days LLJ Hospital Bill Payment Receipt
ssoo Hospital Discharge Summary
b) Claim for Domiciliary Hospitalization No (If yes, provide details in annexure) , 7 27 Pharmacy Bill
Operalion Thealre Noles

c) Details of Lump sum / cash benefit claimed:

=
ECG
Rs i. Surgical Cash: Rs Doctor's requestfor investigation
. Hospital Daily Cash
iv. Convaloscence s. Ihvestigation Reports (including CTIMRUUSGHPE)
ii. Critical illness Benefit Rs
v. Pre/Post Hospitlaization vi. Others Rs Doctor's Prescriptions
Lump sum beneiit
R II Total
Rs. Others
DETAILS OF BILLS ENCLOSED

SL. No Bill No. Dale Issued Dy Towards Amournt (Rs)

Hospital Main Bll
LPra-hospltalization Bil Nos. 26
LPost-hospitalization Bill: Nos
Pharmacy Bills
DECLARATION BY THE INSURED:
Ihereby declare that the information fumished in this claim formis true &cotect to the tbest of myknowledgeand betief If I have made anyfatse or untrue statement, suppression or
concealment of any material fact with respect to questions asked in relation to this clam, my right to claim reimbursement shall be torfeited afso consent & auttonise
TPAnsurance company.to seck necessary medical ntormation / documents from any hospital /Medical Practitloner who has attended on the person against hm thisdlaim
made. I hereby declare that i have included all the bills / recopts for the purpose of this claim & thal I wll not be making any Supplemertary dlaim ercept the prelpost-nOspitalizati
claim, if any

Date Place
Barda Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM - PARTA (To be filled in by the insured)

DATA ELEMENT FORMAT

DESCRIPTION
SECTIONA DETAILS OF PRIMARY INSURED

a) Policy No Enter the policy nuniber Asalloted by the insurance compary

b) SI. No./Certificate No. Enter the social insurance numbor of the certilicate As allotted by the organization
of social health insurance scheme
number
Enter the TPA ID No. License number as alotted by IRDA and
c) Company TPA ID No.
printed in TPA doCumernts

d) Name Enter the full name ofthe policyholder Surnarne, First nare, Middle narre
e Address Enlorthe full postal address Includestreet, City and Pin Code
SECTION B-DETAILS OFINSURANCEHISTORY
al Curently covered by any other Indicate whether currently covered by another Tick Yes or No

Mediclaim/ Health Insurance Medicliam/ Health Insurance

b) Date of Commencement of first insurance without break Enter the date of commencement offirst insurance Use dd-mm-yyforrnat
full
C) Company Name Enter the full name of the insurance company Name of the organization in
Policy No Enter the policy number Asalloted bytheinsurance company
Sum Insured Enter thetotal sum insured as perihe policy In rupees
d) Have you been Hospitalized in the last four years since Indicate whether hospitalizod in the last four years Tick Yes or No
inceptionof the contract?

Date Enter thedate of hospitalization User mm-yy 1ormat

Diagnosis5 Enter the diagnosis delaiis Open Text
e) PreviOUsly Covered by any other Indicate whether previously covered by another Tick Yes or No
Mediclaim / Health Insurance?
mediclaim/Health Insurance
|Name of the organization in full
f) Company Name Enterthefull name of theinsurance company
SECTION C DETAILS OF INSURED PERSON HOSPITALIZED
a ) Name Enter the full an of the palient
l lname Surname, First name, Middle name

b) Gender IndicatoGender ofthe patient Tick Male orFemale

C)Age Enterage of the patient LNumber of years and months
d) Date of Birth Enter Date of Birth of patient LUse dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder. Tck the right option,if others, please specity_
Occupation Indicate ocCupation of pationt Tick thoright option, if others, please specify
9i Address Enter the full postaladdress Include street, City and Pin Code
h)Phone No Enter the phone number of patient Include STD code with telephone number
i)E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D-DETAILS OF HOSPITALIZATION
a) Name of Hosptal where admitted Enter the name of hospital Name of hospital in full
b)Room category ocCupied Indicale the room category occupled Tick the right option
c) Hospilalizalion due lo Indicatereason of hospitalization Tick therighl option
d) Date of Injury / Dale Disease first detected Enter the relevant date Use dd-mm-yy format
/ Dale ol Dellvely

Enter dale of admission Use dd-mm-yy tormat

e) Date of admission
Enter time ol admission Use hh:mm tormi
Time
9) Date of discharge Enter date of discharge Use dd-mm-yy format
n ne Entertime of discharge Use h:mm format
Tick the right option
1) I1 injury give cause Indicatecause ofinjury
Indicate whether injury in medico legal
If Medico legal TIckYes or No
Reported to Police Indicate whether police report was flled TIck Yes or No

MLC Report &Police FIR attached Indicatewhether MLCreportarid Police FIR attached Tick Yes or No
) System ofMedicine Enterthhe system of medicine followed in lrealingthe paliont Open Text
SECTION E -DETAILS OF CLAIM
a)Details of Treatment Expenses Entertheamount claimed astrealment oxpenses Inrupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicatewhethher claim is for domiciliary hospitalzalion TickYes or No
C) Details of Lump Sum/cash benetit claimed Enter the amounl claimed aslurrnpsun /cash bonotit Inrupees (Do not enter paise values)_
d Claim Documents Submilled-Check List Indicatewhich supporting documents are subrmitted Ticktheright option
SECTION F . DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amounts in rupees

 CLAIM FORM -PART B
TO BE FILLED IN BY THE HOSPITAL
The ssue of this Form is not to be taken as an admission of habiity
HERITAGE HEALTH Please include the original preauthorization request Form in lieu of PART A
(To be illed in block let'ers)
IRDAI License No. 008
DETAILS OF HOSPITAL

a) Name of the Hospital

b)Hospital ID c) Type of Hospital: Network Non Network ( fnon network fil section E)

d) Name of the treating doctor SALONI|Pka 5A PabDI

9Regstratlion No. with State CodeO-IkE11) Phone
No
alolalb3 |RZ
e) Qualification Co3-4y)
DETAILS OF THE PATIENT ADMITTED

a) Name of the patient

LIL)Gender MaleFemale d ) Age: Years3uMonths of ) Date Brth:2 4o6 6 ]

b)IP Registration Number L i Time 2 s
h) Dateof Discharge: 2 ol2l1
Date of Admission 2s102 9 Time
) Matemity 1) Date of Delivery
if J L cenca Status
i) Type of Admission EmergensyPlanne
Day Maternily
Care m) Total claimed amount
Discharge to home Discharge to another hospital Deceased
1) Status at time of discharge

DETAILS OF AILMENT DIAGNOSED (PRIMARY) L127

ICD 10 PCS Description
a) ICD 10 Codes Description
Procedure 1
. Primary Diagnosis
bl f e d , h e o d e
ii. Procedure 2
i. Additional Diagnosis

. Procedure 3
I. Co-morbidities

iv. Details of Procedure

Iv. Co-morbidities

c) Pre-authorization obtained:
d) Pre-authorization Nurmber: T I H
If authorization by network hospital not obtained. give reason:
e)
Substance abuse/ alcohol consumption
Hospitalization due to injury: Yes if Yes, give cause Self-inflicted
No i. Road Traffic Accident|
i. If Injury due to Substance abuse/alcohol consumption, Test Conducted to establish this: Yes No (If Yes, attach reports) ii. If Medico legal: |Yes No

iv Reported to Police

vi. If not reported to police give reason

CHECK LIST
CLAIM DOCUMENTS sUBMITTED-

Claim Form duly signed Investigation reporls

Original Pre-authorization request CT/MRI/USG/HPE investigation reports

Doctor's reference slip for investigation
Copy of the Pre-authorization approval letier

Copy of photo ID card of patient verified by hospital CG

harmacy bills
Hospital Discharge Summary
MLC reporls & Police FIR
Operation Theatre notes
Original death summary from hospital where applicable
Hospital main bill
Hospital break-up bill Any other,please specify
ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital - A MARAaAR SoleHEbZTARONAC HAL8O D

Ciy ADeTARA I 1I suto ARAT|
Pin Code: 9 o 213 b Phone No 7 13o|||8 i l s Registotion No. with StateCod
d) Hospital PAN
OT esNo
e) Number of Inpaluent beds:
AMEET WOMNSHOSPITAL
Facililies available in the hospital . ICU
Yes o D-14, Amarnagaf Society.
ii)Others: Near SamtaChar Rasta,AnunachalRoad
Subhanpura, VADODARA-390023.
 DISCHARGE SUMMARY
Name of Patient: Uma Kumari age:34/F
Mobile No.
Tel No.
IPD No. 02/2021 Admission No.
Treating Consultant/s Name DR SALONI PRAJAPATI

25/10/2021 Time of Admission 11:30 AM

Date of Admission
Date of Discharge 26/10/2021 Time of Discharge 12:45 PM

MLC No./ FIR No. Abnormal Uterine Bleeding wn neadache

Provisional Diagnosisat the time of Admission neadorhe
inal Diagnosis at the time of Discharge Abnormal Uterine Bleeding
CD-10 code(s) or any other codes, as recommended N93.9

by the Authority,for Final diagnosis
Presenting Complaints with Duration and Reason
for Admission
Summary of Presenting liness
Key findings, on physical examination at the time of
admission
History of alcoholism, tobacco or substance abuse,
Patient has history of irregular menstrual cycle since
1 month .Clo heavy bleeding per vagina and passing
clots.
complain of bleeding pv and weakness
Gc: Fair. no edema,palpitation.].icterus,clubbing9
No any significant personal history.

ifany
Significant Past Medical and Surgical History, if any Not significant
Not significant
Family History if significant/relevant to diagnosis or
treatment
Summary of key investigations during
Hospitalization
ourse in the Hospital including complications, if patient admitted with complain of heavy bleeding and
weakness. so medical managment given for bleeding
any
Rest. do CBC,TSH,S. VIT B12 AND VIT D3 TEST
Advice on Discharge
Name of treating Signature of treating
Consultant/ Authorized DR SALONI PRAJAPATI Consultant/ Authorized
Team
Doctor Team Doctor
Name of Patient/ Signature of Patient/
Attendant
Attendant
DR. SALONI PRAJAPATI
NIRMEET wOMEN'S HOSPITAL
M.D, 08S GYWAEC D-14, Amarnagar Sociely.
REG. NO.G-18371 Near Samta Char Rasta, Anunachal Road,
Subhanpura, VADODARA-390023.
 Dr. Viral Patel
M.D. Pathology
NABL
MC-3742
PATHOARE PATHOLOGY LABORATORY
TEST REPORT
Acc. ID : 211043399
Name UMA KUMARI
Regd. Dt 27-Oct-2021 09:18 AM
Age/Sex 34 Years I Female Birthdate

Refd. By :DR. SALONI PRAJAPATI Status : Final Coll Dt. TM. 27-Oct-2021 08:50 AM
Recd. Dt. Tm. 27-0ct-2021 09:18 AM
Sample :EDTA PassportNo Report Dt. Tm.: 27-0ct-2021 09:48 AM
Client Details RACE COURSE Mobile : 9458247613

HEMATOLOGY

Result Unit Biological Ref. Interval

Test Name

COMPLETE BLOOD COUNT (CBC)

Done on SYSMEX XN-350 FULLY AUTOMATIC HEMATOLoGY ANALYSER

HEMOGLOBIN 11.7 9% 12.0-16.0

SLS-Hemoglobin Method

RBCs COUNT 3.84 million/cmm 4.2-6.2

EIectric timpedance
4000 - 11000
WBCs COUNT TOTAL 5250 cmm

DIFFERENTIAL COUNT: WBC (Flowcytometry)

63 60-70
POLYMORPHS

LYMPHOCYTES 30 20-30

EOSINOPHILS 03 1-6

MONOCYTES 04 2-6

00 1
BASOPHILSs

Absolute Count (Calculated)

3308 cmm 1700 7000
NEUTROPHILS (Abs)
1575 Icmm 1000 4800
Lymphocytes (Abs)
50 - 500
EOSINOPHILS(Abs) 158 cmm

210 cmm 300-900

Monocytes (Abs)
Icmm 0- 30
Basophils (Abs)
Neutrophil-Lymphocyte Ratio (NLR) 2

BLOOD INDICES

P.C.V 36.0 oo 37-42

RBC HIStogran

This is an Electronically Authenticated Report.

Dr. VIRALA. PATEL Dr. VIRAL A. PATEL

Verified By
M. D. PATHOLOGY M. D. PATHOLOGY
GMC No. G-22658
Akshara Bhabhor GMC No. G-22658
Page 1 of 4

Main Lab:
430, Trivia Complex, Natubhai Circle, Race Course, Vadodura. 0265 298 3000 | 8980804340 pathocarelab2013@ gmail.com
-

CC1:105.Senaue Square Tower B, Opp. Gangotri Complex, 30 Meter Roud, Op. Yash C'omplex, Gotri, Vadoudara.
cC 2: 203. Phocnix Prime, Nr. L&T Circle, Karelibaug, Vadodara 0265 296 1489 8980804387 pathocarelab2@gmail.com
 Dr. Viral Patel
MD Pathology
NABL
MC-3742
PATHOARE
PATHOLOGY LABORATORY
TEST REPORT
Name Acc. ID 211043399
UMAKUMARI
Age/Sex :34 Years Female Birthdate Regd. Dt :27-Oct-2021 09:18 AM
Refd. By :DR. SALONI PRAJAPATI Status :Final Coll Dt. TM. :27-Oct-2021 08:50 AM
Sample EDTA PassportNo: Recd. Dt. Tm. :27-Oct-2021 09:18 AM
Client Details RACE COURSE Moblle 9458247613 Report Dt. Tm. : 27-Oct-2021 09:48 AM
M.C.V 93.8 fL 82-92
Calcdated
M.C.H 30.5 Pg 27-31
Cakulated
M.C.H.C 32.5 % 32 36
Calculated
RDW (Calculated) 14.7 11-14
RBC Hisiogramm

PLATELET COUNT 255000 /cmm 150000 - 450000

tectnc Inupetanc

Complete blood count investigation contains estimation of Haemoglobin, RBC indices, total leucocyte count, differential leukocyte count and platelet count.

Range of CBC parameters varies according to age and sex of an individual.

Hemoglobin estimation is indicated in case of typing of anaemia, SCreening of polycythemia, to assess response to specific therapy in anaemia, and for
selection of blood donors.

Total leukocyte count refers to the number of white blood cells in 1 ul of blood.

Physiological causes such as exercise, labour, pregnancy, and emotional stress can also cause elevated leucocyte count.

TLC is deranged in cases of infections (bacterial / viral / parasitic/fungal), acute blood loss, tissue necrosis, myeloproliferative disorders, leukaemia, and
metabolic disorders.

Platelet count indicates quantitative or qualitative disorders of platelet and cause of bleeding.

Reterenoe- Wintrobe's Cliical Hematology. 14h ed Greer J, edilor. Philodelphia, PA: Wolters Kluwer: 2019, Saction 2: The Eryhrocyte, Pp 1512-1516
1522-1524
Harmening, D. Clinical Hematology and Fundamentals of Homostasis, Fith Editilon, FA. Davis Company, Philedelphia, 2009, Chapter 3 and pp 305-328.

This is an Electronically Authenticated Report.

Dr. VIRAL A. PATEL Dr. VIRALA. PATEL

Verified By
M. D. PATHOLOGY M.D. PATHOLOGY
GMC No. G-22658 Akshara Bhabhor GMC No. G-22658
Page 2 of 4

Main Lab:
0265 298 3000 8980804340 pathcarelab2u13a gmail.com
430. Irivia Complex, Natubhai Circle, Race Course. Vadodara.
Viadodara.
CC1: 105, Senate Square Tower B, ( omplex, 30 Meter Road. Op Yash Connplex, Gotrn,
Opp. (iangotri
03 Phix Prmc. Nr. L&T Cle, Karclibau, Vaoular 0265 29% 1489 S9sOsOU87 pathocaretab ,t emailcom
 Dr. Viral Patel
M.D. Pathology

PATHOARE
PATHOLOGY LABORATORY
TEST REPORT
Name
:UMA KUMARI Acc. D 211043399
Age/Sex 34 Years IFemale Birthdate: Regd. Dt 27-Oct-2021 09:18 AM
Refd. By
DR.SALONI PRAJAPATI Status:Final Coll Dt. TM. 27-Oct-2021 08:50 AM
Sample Serum Recd. Dt. Tm. 27-0ct-2021 09:18 AM
PassportNo:
Client Details: RACE COURSE Mobile 9458247613 Report Dt. Tm. : 27-Oct-2021 10:09 AM

IMMUNOLOGY
Test Name Result Unit Biological Ref. Interval

TSH 1.960 IU/ml 0.4-4.2

CHEMIL UMIINESCENT MICROPARTICLE MMUNOASSAY
Thyroid stimulating hormone (TSH) is synthesized and secreted by the anterior pituitary in response to a negative
feedback mechanism involving concentrations of FT3 (free T3) and FT4 (free T4). Additionally, the hypothalamic
tripeptide, thyrotropin-relasing hormone (TRH), directly stimulates TSH production. TSH stimulates thyroid cell
production and hypertrophy, also stimulate the thyroid gland to synthesize and secrete T3 and T4. Quantification
of TSH is significant to differentiate primary (thyroid) from secondary (pituitary) and tertiary (hypothalamus)
hypothyroidism. In primary hypothyroidism, TSH levels are significantly elevated, while in secondary and tertiary
hypothyroidism, TSH levels are low. TSH test is done by Third generation TSH (TSH-Ultra) assays. Third
generation TSH assays are defined by the functional sensitivity. It has far superior precision in the subnormal TSH
range compared to second and first generation assays.
S. Vitamin B12 Level 1000 Pg/m Deficient 32 - 145
Insufficiency: 145 -239
Normal: 239 931
CHEMILUMINESCENT MICROPARTICLE IMMUNOASSAY

Introduction : Vitamin B12, a member of the corrin family, s a cofactor for the formation of myelin, and along with
folate, is required for DNA synthesis. Levels above 300 or 400 are rarely associated with B12 deficiency induced
hematological or neurological disease. Clinical Significance: Causes of Vitamin B12 deficiency can be divided into
three classes: Nutritional, malabsorption syndromes and gastrointestinal causes. B12 deficiency can cause
Megaloblastic anemia (MA), nerve damage and degeneration of the spinal cord. Lack of B12 even mild
deficiencies damages the myelin sheath. The nerve damage caused by a lack of B12 may become pemanently
debilitating. The relationship between B12 and MA is not always clear that some patients with MA will have normal
B12 levels; conversely, many individuals with B12 deficiency are not afflicted with MA. Decreased in: Iron
deficiency, normal near-term pregnancy, vegetarianism, partial gastrectomy/lileal damage, celiac disease, use of
oral contraception, parasitic competition, pancreatic deficiency, treated epilepsy and advancing age. Increased in:
Renal failure, liver disease and myeloproliferative diseases. Variations due to age Increases: with age.
Temporarily Increased after Drug. Falsely high in Deteriorated sample.

This is an Electronically Authenticated Report

Dr. VIRALA. PATEL Dr. VIRALA. PATEL

Verified By
M. D. PATHOLOGY M. D. PATHOLOGY
GMC No. G-22658 GMC No. G-22658
Page 3 of 4

Main Lab:
430, Trivu Complex. Naubhai Circle,Race Course, Vadodara. 0265 298 3000 | 8980804340 pathocarclab2013@ gmuil.com
CC1: 105. Senate Square Tower - B, Opp. Ciangotri Complex. 30 Meier Road, Opp. Yash Complex, iotri, Vadodara.

CC2:203. Phocnix Prime, Nr. L&T Circle, Karelibaug, Vadodara. 0265 296 1489| 8980804387
pathocarelab2a gmail.com
 Dr. Viral Patel
M.D. Pathology
PATHOARE
PATHOLOGY LABORATORY
TEST REPORT
Name :UMA KUMARI Acc. ID :211043399
Age/Sex : 34 Years I Female Birthdate Regd. Dt : 27-Oct-2021 09:18 AM

Refd. By :DR. SALONI PRAJAPATI Status Final Coll Dt. TM. :27-Oct-2021 08:50 AM
Sample Serum PassportNo: Recd. Dt. Tm. : 27-Oct-2021 09:18 AM
Mobile : 9458247613 Report Dt. Tm. :27-Oct-2021 10:09 AM
Client Details
: RACE CoURSE
25 OH VITAMIN D TOTAL 27.90 ng/mL Deficiency: <20
Insufficiency 20-30
Sufficiency 30-100
Toxicity: > 100

CHEML UAINESCENCE IMMUNOASSAY

Vitamin D is a fat soluble hormone involved in the intestinal absorption and deregulation of calcium. It is
synthesized by skin when sunlight strikes bare skin. It can also be ingested from animal sources. Vitamin D is
bound to the binding protein (albumin and vitamin D binding protein) and carried to the liver. In the liver it is
transformed in to 25 hydroxy-vitamin D (calcidiol), which is the primary circulating and the most commonly
measured form in serum. Then in the kidney it is transformed in to 1,25 dihydroxy-vitamin D (calcitriol), which is
the biologically active form. Vitamin D plays a vital role in the formation and maintenance of strong and healthy
bones. Vitamin D deficiency has long been associated with rickets in children and osteomalacia in adults. Long
tem insufficiency of calcium and vitamin D leads to osteoporosis. There have been multiple publications linking
vitamin D deficiency to several disease states, such as cancer, cardiovascular disease, diabetes, and autoimmune
diseases.

- -

End Of Report-

This is an Electronically Authenticated Report.

Dr. VIRALA. PATEL Dr. VIRAL A. PATEL

Verified By
M. D. PATHOLOGY M. D. PATHOLOGY
GMC No. G-22658 GMC No. G-22658
Page 4 of 4

Main Lab:
430, Irivia Complex, Natublai Circle, Race Coursc, Vadodara. (0265 298 3000 8980804340 pathocarelab2013@ gmavl.com

CC1: 105. Senate Square 1ower - B, Opp. Gangotri Complex. 30 Meter Road, Opp Yash Complex, Ciotr1. Viadaskara

CC 2: 203. Phocnix Prime, Nr. L&T Circle, Karelibaug. Vadodara 0265 296 1489 88O804387 pathocarelab2 t pmail com
PATHCARE
PATHOLOGY LABORATORY
Test Requisition Form
F/PEP/02
Rev 00

Date: 2 6 L ) Location:.

Patient's Name: na dn Contact.

Age: Gender: Male Female E-mail:

Ref. Dr AdLAni hd100) Contact-

TEST REQUESTED:

CBC
5.5

le

PATIENTs CLINICAL HISTORY/ INFORMATION:

A headache

COR LABORATORY USE: Signature of Ref. Doctor

Specimen Collection Time: Collected by:

sssesseos*sssoasnusssssoo***o***s*soasaress*******n*******

Sample Types & No. (Collected).

Time of sample received at lab:

******************************************************************************************** *****ensosnsnnse***********sceneanese

Remarks:
** ***************************************************************.**********sensenneene*******i*aneennsnp**ntnnassesssnerenne*ssnosenue**aone***

Main Lab: 430, Trivia Complex, Nr. Natubhai Circle, Rececourse, Vadodara 390 007.
Ph.:898 080 4340, 0265-298 3000 E-mail: pathocarelab2013@gmail.com
Molecular Unit: 419, Trivia Complex, Nr. Natubhai Circle. Racecourse, Vadodara.
Ph.: 749 004 5472, 749 004 5473 E-mail: mdu.pathocare@gmail.com
 Nirmeel Women's Hospital
Dr. Saloni Prajapati sY. Icloî uaufa
M.D. (Obstetrics and Gynecology)

Uma

C DS

JV stt 2
V Comla mo. o )
lo ol Snge Tneede -(M
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Camfi*)

dYiigioll iaje
CONSULTING TIME
(Monday to Saturday)
H2:10.00 1.00 Morning: 10 am to 1 pm,
HiY :4.00 Å 9.00 Evening :5 pm to 7 pm.
Please take appointment for your convenience

S1-1, 8IPo1PR, 213IRIA AIS, HAdI eIr e2di Yei, CioYel, qsleRI-3G0023. 1: CvL01UTUO
D-14, Amarnagar,Arunachal Road, N. Samta Char Rasta, Sutbhanpura, Vadodara-390023, M:8780181150
 rmed Women's Hospital
si. Hciio uaufa
Dr. Saloni Prajapati
M.D. (Obstetrics and Gynecologv)

Xna

db. Chleralnteol
CGok1 U)-

CONSULTING TIME
(Monday to Saturday)
HIe: 10.00 4.00 Morning: 10 am to 1 pm,
i : 4.00 l 9.00 Evening:5 pm to 7 pm.
Please take appointment for your convenience

S-17, tR1PR, 1SQIRIG eIs, 2Hacdi eIre edi uel, gelonyei, asleel-ac0o23. oîl: coL01¢11uo
D-14, Amanagar, Arunachal Road, Nr. Samta Char Rasta, Subhanpura, Vadodara-390023, M: 8780181150
 Nirmeel Women's Hospital
Dr Saloni Prajapati si. eictol uauld
Obstetrics and Gynecology)

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CONSULTING TIME
(Monday to Saturday)
Hqie: 10.00 1.00 Morning: 10 am to 1 pm,
e1:4.00 .00 Please take appointment for your convenience
Evening:5 pm to 7 pm.

S-17, 21eot Ie, 2130IRIG AS, HHdl eIie zedi yiel, gololyei, qsleeI-3cO023. l: coLo1L1LU0
D-14, Amarnagar,Arunachal Road, Nr. Samla Char Rasta, Subhanpura, Vadodara-390023, M: 8780181150
 Nrmeelrmeel
Women's Hospital
Dr. Saloni Prajapati si. 2Icnoi uaufa
M.D. (Obstetrics and Gynecology)

Uma kumuan , Fl 2S1ol2u2

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CONSULTING TIME
(Monday to Saturday)
2HGI2: q0.00} 1.00 Morning :10 am to 1 pm,
Hi? :u.00 9.00 Evening:5 pm to 7 pm.
Please take appointment for your convenience
S-1, 1oPR, A3I2ICI s, evii e2 2edi und, Yeolyel, eslsel- 3coo23. oì: cvc01<11uo
D-14, Amarnagar, Arunachal Road, Nr. Samta Char Rasta, Subhanpura, Vadodara-390023, M: 8780181150
 1

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Women's Hospital
Dr. Saloni Prajapati sf. eIcinof uaufa
M.D (Obstetrics and Gynecology)

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NIRMEET wOMEN'S HOSPITAL

D-14, Amarnagar Society.
Near Samta Char Rasta, Arunachal Road,
ubhanpura, VADODAQNSULFING TIME
Monday to Saturday)
Hq: 10.00 1 1.00 Morning : 10 am to 1 pm,
HI4.0021 6.00 Evening: 5 pm to 7 pm.
Pleasetake appointment for your convenience
SI 17, 1eole, 13leIH PI>, i n i «Ile vecti utel, qYttonga, qsl&e1 360o23. l : cvC01C1140
D-14, Amarnagar Arunachal Road, Nr Samta Char Rasta, Subhanpura, Vadodara-390023, M 8780181150
 Dr. Shivakumar S. Donagaon Dr. Aneri Thakkar
ISHAN
IMAGING
MB.B.S D.MRD
DNB (Radiodiagnosis)
M.B.BS. DNB (Radiodiagnosis)
MNAMS. FRCR(UK)
1.5 T MRI
101-106. Shyam Arena. 14, Sampatrao Colony. Opp Circuit House. Laxmi Hall Lane.
Alikapuri, Vadodara 390 007 Ph.: 0265 235 0274, 79840 08474, 79903 12559 Multilice CT Scan
E: ishanimaging@gmail.com Sonography / Doppler
Digital X-Ray
REFERRAL FORM Digital Mammography

Name '****'**'''' ' ' ' ' * ' ' *****''''

Age/Sex f/32
Ref. Dr. 0n Date 11-12-
CLINICAL HISTORY /INVESTIGATIONS NSHadache. 1

S. Creatinine Metallic Implants Pacemaker

Allergy. .

MRI (Take Prior Appointment) CT SCAN

Brain Brain KUB/IVP

Spine Chest/ HRCT Joints

Body Abdomen Angiography

Joints Others
**''**********'****''** ''***'**************

*'************

************ **

USG/ DOPPLER
Abdomen KUB Small Parts Digital X-Ray Sonomammography
MSK OBG Doppler Others Digital Mammography
Other (Please Specify)

Time: Mon-Sat 9 am -8 pm | Sunday - Emergency EMERGENCY 24x7 AMBULANCE SERVICE AVAILABLE

 SATYAM MEDICINES
G/3/3A,AAKAR COFLEX, SAMTA CHAR RASTA,SAMTA Phone:
Dr.Nane: DR SALONI PRAJAPATI BILL OF SUPPLY BiliNo 1975
Patient U KRI Date:09/11/21
Address
Oty Product FG Padk Batchh Exp EP STZ GAnt unt
8/0 D UIK GRAMLES EDU *1 PAC PMAE% CB/22 32.50 12.0 27.86 260.02

DAL No.GJAD-181745 GJVAD-181746 Total 232.16

ST ND 244EHT8130R1ZT,DT:30/12/99 Cst 27.86.
VADODARA Jurisdicatin Disc Ant 0.00
E.&0.E. Subject to
Grand Total 260.00
 LIFE
G3
LINE MEDICINES BILL OF SUPPLY CASHMO BDJPR1027F
ANJANA PARK MPLEX.UNDER BHAF
(M9429038014 HOSPITAL NEW
IPCL,SUBHNPURA, VADODARARIERIA GSTIN NO 24e0PR1027F12T
Customer UMAKUMARI
Doctor Area: BatlNo
SALONI PRAJAPATI :CRA
Sr. Mobile
Description Mfg Pack
Date 2510r/2021
1 BatchNo ExpDt Qty Rate
DNS 50OML BOTTLE INJECTION OTS 500ML 1213746
GrossAmt Disc Amount
2 MVI INJECTION 07/24 1 34.46 34.4 0.00 34.46
3 TRAPIC MF TAB USV 1OML NP21226 10/22 25.00 25.00 0.00 25.00
SUN 10 GTC1203A 05/23
4 OROFER XT TAB
EMG 10 1 359.00 359.00 0.00 359.00
5 TRENAXA INJECTION E16GL21054 05/23 3 156.90 470.70 0.00 470.70
|MAC 1 TRA0102001 03/22 78.19 78.19 0.00 78.19
SUBJECT TO VADODARA JURISDICITON
7 967.35 0.01 967.35
D.LNO 20B GJ-VAD-153213,21B G-VAD-153214,20C GJ-VAD-1532155 For, LIFE LINE MEDICINES OTHER4
0.00
ROUND
ROUND OFF 0.35
Rupees Nine Hundred Sity Seven Only
Software by VISUAL INFOSOFT PVM. LTD. : Customer E.&0.E. ChebnistSign NET 967.00
Care No: 079 3520 7999
 PATHOARE
PATHOLOGY LABORATORY
419/430, TRIVIA COMPLEX, NATUBHAI
CIRCLE
RACE-COURSE, VADODARA
Mo: 8141403640, 8980804340
Landline: 02652983000
Email: pathocarelab2013@gmail.com

BILL CUM RECEIPT

Name UMA KUMARI Invoice No/Date 211043399/27-Oct-2021 09:18

Age : 34 Yrss Gender : Female
Branch 1-Pathocare Email
Client :RACECOURSE Contact No :9458247613
Doctor : DR. SALONI PRAJAPATI
Services: CBC, TSH, VITAMIN B12, VITAMIN D-3 Level

Receipt No Receipt Date Amount Mode Received By Gross Bill Amount 2450.00
R-1-21-22-19238 30-Oct-2021 17:32 2450.00 google pay HARSH.LIM
Net Amount 2450.00
Amount Paid in Words: Two Thousand Four Hundred And Fifty Only Paid Amount 2450.00
Authorized By : MAITREE Balance to Pay 0.00
OCAR
PATHO
KLABOR
ATOR
R Y
 ISHAN 101-106, Shyam Arena, Sampatrao Colony,
IMAGING Reetpt Opp. Circuit House, Laxmi Hall Lane, R C
Dutt Road, Alkapuri, Vadodra - 390007

Receipt No: 15006 Date 12 December, 2021

Received with thanks from MRS. UMA KUMARI
Sum of Rupees Five Thousand Five Hundred Only
Payment Detail(s)
Particuler(S) Amount
MRI BRAIN 4500.00
emergency 1000.00
Total 5500.00

For -ISHAN IMAGING

Images of scan more than 30 days old will not be available in our archives. Please Keep the original films.
Please Keep the original reports and receipt. If lost will be available only in
duplicate at additional cost.

(
ISHAN IMAGINGS
101-106, Shyam Arena,
14, Sanpatrão Colony,
R. C. Dutt Road,
Vadodara 390 007.
-
 meel
Women's Hospital
si. 2iclolt uaufa
Dr. Saloni Prajapati
M.D. (Obstetrics and Gynecology)
Fial B ole Io:o )
otem's m Uma kond. Pge: 3 Y
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Don: 2510: ) Time 209, 6-10 -*). Tne 12,u5 p
'30dn

me hdge: Dr. 5ol0Poajo pdi

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Consaldaskochdres 500- Rs
dinn chdes Ka gool-

.TV dmp chozes l3)oo) Rs. 3ool

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To 550 - .

NIRMEET WOMEN'S HOSPITAL aly

D-14, Amarnagar Society,
Near Samta Char Rasta, Aunachal Road, CONSULTING TIME
(Monday to Saturday)
Subhanpura, VADODARA-390023.
H I I : 10.00 1.00 Morning: 10 am to 1 pm,
HiT :4.00 l o.00 Evening:5 pm to 7 pm.

Please take appointment for your convenience

S1-13, 1RoPR, 13IRIG AS, Hdi eI2 RedI YA, Helolyel, csls1-3¬0023. 3l: t9c01L1140
D-14, Amarnagar, Arunachal Road, Nr. Samta Char Rasta, Subhanpura, Vadodara-390023, M :8780181150
 AXIS BANNK Flipkart
Flipkart Axis Bank Credit Card Statement

AANUJ KUMAR
FLAT NO 804 GROWMORE TOWER,
HARINAGAR, Now Just tap and pay for
VADODARA 390023
purchases up to 5,000.
Io for the symb

Tap the card on the mac hine

Yor re good to go

PAYMENT SUMMARY
Total Payment Due Statement Generation Date
Minimum Payment Due Statement Period Payment Due Date
73,101.44 Dr 3,656.00 Dr 17/11/202115/12/2021 04/01/2022 15/12/2021

Credit Card Number Credit Limit Available Credit Limit Available Cash Limit
for hawle reeprmen
s33467***4730 115,000.00 41,898.56 34,500.00 Auto- Debit a c y on 1 0 9 7

Previous Balance Payments Credits + Purchase + Cash Advance Other Debit&charges =Total Payment Due Mi wwould result in the repirmert
sfretching over ye srs with consequent intere
S5,106.0S Dr 55,200.00 2,647.03 75,842.42 0.0 0.00 73,101.44 Dr

Account Summary
DATE TRANSACTIONDETAILS MERCHANT CATEGORY AMOUNT (R$.) CASHBACK EARNED
Card No: 533467sos*4730 Name MANUJ KUMAR
15/11/2021 AMAZON PAY INDIA CLOTH STORES 599.00 Cr 8.00 Dr

15/11/2021 INDIAN sPICEBARODAIND RESTAURANTS 117.00 Dr 1.00 Cr

15/11/2021 RELIANCE BP MOBILITY LVADODARAIND 0.00 Cr
FUEL 323.84 Dr
16/11/2021 AIRTELGURGAONIN MOTO |48.00 Dr 0.00 Cr
16/11/2021 STERLING ADDLIFE INDIAVADODARAIND MEDICAL 46,000.00 Dr 690.00 C
17/11/2021 |STERLING ADDLIFE INDIAVADODARAIND MEDICAL S,398.00 Dr 80.00 Cr
17/11/2021 IRCTC IPAY ETICKETINGWWW.IRCTC.CO.IND TRANSPORT 1,375.00 Cr 20.00 Dr
GOVT SERVviCES 24.00 Cr
18/11/2021 IRCTCBANGALOREINDD 1,634.39 Dr
2,978.00 Dr 44.00 Cr
18/11/2021 DMARTVADODARAIND DEPT STORES
19/11/2021 osIA HYPERMARTBARODAIND DEPT STORES 473.75 Dr 7.00Cr
22/11/2021 IRCTCBANGALOREIND GOVT SERVICES 1,991.83 Dr 29.00 Cr

22/11/2021 INDIAN SPICEBARODAIND RESTAURANTS 942.00 Dr |14.00 Cr

25/11/2021 B0OKMYSHOWMUMBAIIND ENTERTAINMENT 534.96 Dr 3.00 Cr
55,200.00 cr 0.00 Dr
30/11/2021 NEFT PAYMENT RECEIVED CLOTH STORES 827.66 Dr 12.00 Cr
02/12/2021 FIRSTCRYPUNEIND
05/12/2021 oSIA HYPERMARTBARODAIND DEPT STORES 633.00 Dr 9.00 C
06/12/2021 ADDITIONAL CASHBACK FROM 3.00 Cr 0.00 Dr
DEPT STORES
11/12/2021 oSIAHYPERMARTBARODAIND 633.10 Dr 9.00 cr

IMPORTANT MESSAGE
Axls Bank Maharashtra GST reglstratlon no.27AAACU2414KED

Please ocoeocommitment.aspx
refer thecashbadk mentioned agalnsteach
Pleace eerh for revlsed
transacton for theamountofcashback BCSBIincode
eamed this month's statement. The amount of ashback comed n the curent syde shallbe credited oyour Credit Card acczunt in the
next month's statement

CONTACT US
call 1860 419 55S5 or 1860 500 55S5 Grlevance Redressal
local charges will appiy Nodal Officer,
For any assistance please visit 080 61865200
Your cheque should be payable to Axis Banlk Card No.
axisbank.com/support
S2346770.PeeutevourAME&T O .
reverse of the cheque. Dear Qustomer, pay your Axis Bank Credit Card bi Manager,
5th
Floor,
Customer Care,Axis Bank Ltd.,NPCL,
nedal.otflcer@axlsbank. com

from any bank account by registering for ECS at any Axls Bank branch.
Glgaplex,Plot No 1.T.5, MIDC, Alroll
Visit axisbank.com to download the form.
Knowledge Park, Alroll,
Navl Mumbal-400708
Axls Bank Ltd, NPC1, Sth Floor, "sigaplex", Plot No 1.T.S, MIDC.
Alroll Knowledge
Park, Alroll, Navi Mumbal- 400708

Say yes to secure your Enable online, contactless and

family's future Internatlonal transactlons on the go
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Page: 1 of3
 AXIS BANK
Flipkart
Flipkart Axis Bank Credit Card Statement
DATE TRANSACTION DETALS MERCHANT CATEGORY AMOUNT (R.) CASHBAKEARNED
11/12/2021 CASHBACK CREDIT NOV 2021
640.00 0.00 Dr
11/12/2021 SHREE RANCHHODRAY DEPT STORES 295.00 Dr 4.00 C
12/12/2021 ISHAN IMAGINGVADODARAIND MEDICAL
12/12/2021 DMARTBARODAIND
S,500.00 Dr 82.00 Cr
DEPT STORES 3.504.95 or 52.00 Cr

13/12/2021 PAYTMNOIDAIN MOTO 470.82 Dr 7.00 0

13/12/2021 RELIANCE BP MOBILITY LVADODARAIND FUEL 3,036.12 Or 0.00
14/12/2021 FLIPKART PAYMENTSGURGAONIND DEPT STORES S00.00 Dr 25.00 Cr
15/12/2021 FUEL CASHBACK REBATES 30.03 C 0.00 Dr
***
End of Statement***
 To Faizan Dangiwala
B
+91 *****5940 To BharatPe Merchant
To Alka Patel
91 94275 79182

2,450.00 1,000.0o
Completed Oct 27, 8:54 AM Pay To LIFELINE MEDICINES
2,500.00
Completed Oct 25,11.11 AM Completed.Oct 25,148PM
Union Bank of India XXXXXX5897
U n l o n Bank of India XXXXXX5897
U n i o n Bank of Indie XXXXXX5897
UPI transaction 1D
130033089549 UPI transoction ID
UPI transactlon ID
129809454499
To: Mr. DANGIWALA MOHAMAD FAIZAN
129807097168
To: ALKA ROHITBHAI PATEL
taizandangwala23@okhdfcbank To: BharatPe Merclhant
bharatpe09892614433@yesbankltd alkapateli 1081982@okicdc
From: MANUJ KUMAR (Union Benk of India)
From: MANUJ KUMAR (Union Bank of India) From: MANUw KUMAR (Union Pank of indio)
manuj.banker-1@okhdfebank
manu,.banker-1@okhdfcbenk manu.banket:1@okhdfcbank
Google traonsactlon DD
Google transaction 1D Googte transaction 1D
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Pay GPay GPay

S
To SATYAM MEUICINES

800
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G a p l e l te N v 9, 3.62 PM

U n i o n Bursk of lndia XKKXRADI*

UPitransaction D

131335O7B895

To: SATYAM MED!CINES

***
1439

From: UMA KOMARI {Uníon Bank o f n d í a l

umagaug Klafcbank
GGOOalE transation 1
CEAQGCZ5etONSA

Pay