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License No.028)
Cambata Building (Eros Theatre Building), East Wing, 3rd Floor, 42, Maharshi Karve Road,
Churchgate Mumbai 400 020.
_____________________________________________________________________
PART A-TO BE FILLED IN BY TREATING CONSULTANT
Date: _____________
Please attach copy of patient photo id and DHS id card copy with this form.
Particulars
Hypertension
IHD
Osteoarthritis
COPD/ Bronchial Asthma
Yes/ No
since when
Particulars
Diabetes
Yes/No
1
Since when
2
Cancer
Alcohol / Drug abuse
5
6
Maternity cases: Gravida_____Para___Living____LMP______
Details
Particulars
Room Rent+ Nursing Charges
Surgeon Fees
OT Charges/Anesthesia/Consumables
Doctor Consultation / Visits charges
Investigation charges
Medicines Charges
Total Amount
Service Tax
Grand Total
wrong and/ or misleading and/or incorrect information regarding the duration of ailments and/or other historical information
regarding my (patients) health status/. I acknowledge and agree that information provided by me are true and up to the best
of my knowledge.
Previous policy details: Policy No.______________________________ Insurance Company: ________________________
Concurrent Policy details: ____________________________________ Contact Info: ______________________________
Signature. _______________________________ Name: ___________________________________________________