Documente Academic
Documente Profesional
Documente Cultură
A.
Personal Details 1. 2. Name Birth Details / / Time Of Birth (24)(hrs min) Place Of Birth (Village, City, State)
City 4. 5. 6. 7. Contact Nos E Mail ID (if available) Qualification / Profession Who referred you to this office? Land Line
State Mobile No
PIN
B.
Patient ID
I I H C C No. 95, 20th main,8th cross, G-Block, Sahakara Nagar, Bangalore 560092, India Website: www.ihhp.net Email: ihhp.blr@gmail.com Tel : +91 934 122 1944, 080-23532184 For IIHCC use Only: Registration received / Patient ID : Reference Folder : Allotted Date/ Sign:
D. No
Present Ailments (Use separate sheet if required Complete Information Required) Disease Name Treated Where Medicines Taken Dosage Present Status
Patient Declaration All above data are given at my free will and I approached the ashram on my own for my ailment.
I I H C C No. 95, 20th main,8th cross, G-Block, Sahakara Nagar, Bangalore 560092, India Website: www.ihhp.net Email: ihhp.blr@gmail.com Tel : +91 934 122 1944, 080-23532184 For IIHCC use Only: Registration received / Patient ID : Reference Folder : Allotted Date/ Sign: