GOVERNMENT OF INDIA

MINISTRY OF HOME AFFAIR

33 ASSAM RIFLES
AYUSHMAN CAPF REFERRAL SLIP
OPD No : -
Name of Patient : SOMA CHAKRABORTY Relation : Wife Age : 50 Yrs
Sex : F:
Regtl No: JC-380052A Rank: Sub (B&R) Name : Gautamn Chakraborty
Unit : HÌ9 Sect Assam Riles Pin-934829 C/o 99 APO.
Ayushman CAPF card No :PRUFEPDR Referral No: 2333
Mobile No : 8974519420

Chief Complaints
Diagnosis:

Brief summary of the case and positive findings.

dihee
Dn) mmedh'
Investigtton &thattat (?yfe

Type of Referral
OPD/IPD/DIAGNOSTIC
Components of referral/
Consultation/ Investigation/ Procedure/Any other (Please Specify)
cetnt
AYUSHMAN CAPFs:
Referral to Govt/Private Hospital empanelled fór

Signaturewith aafeal office

Name ..Co...
RedRaAPMc/gÜ340
Mar
Dated
AYUSHMAN CAPF card on
Note : This referral slip is valid for treatment against
Valid Period
One month : Consultation/ Investigation
1.
Three month Foil Procedure
2. Dialysis / Chemotherapy
3.
Six nmonth: