JINDAL NATURECURE INSTITUTE JINDAL NAGAR, TUMKUR ROAD, BANGALORE 560073 APPLICATION FORM Personal Details

Patients Name: Co-patients name with Relationship if accompanied (Submit a separate application) Gender Date of Birth Age Marital status Father / Husbands name Full Postal Address Pin code Telephone / Mobile Fax E-mail Occupation Married / Unmarried Country Nationality

Passport Details
Passport No. Date of Issue Place of Issue

Accommodation Details
Type of Accommodation desired Total number of days desired Date from which accommodation Required Alternate Date from Details of Reservation Deposit Annual Income from all sources (only in case of Free Ward) From : From : To : To :

Browse Tariff Table

In case of re-admission, please write

Previous date of admission Height Weight BP Appetite

M.R. Number Sleep

Accommodation Urination Bowels Menstrual Cycle

Personal History

Disease particulars
Details 1 2 3 4 5 Please answer the following: 1 Have you undergone any operation the past 3 months? If yes, give details. 2 Do you suffer for any type of Hernia? If yes, give details. 3 Do you suffer from any kind of skin disease? If yes, give details 4 Have you suffered from Heart ailment in the past? If yes, give details. 5 What medicines are you taking at present? 6 Habits (Tea / Coffee / Smoking/Alcohol / Drug addiction / Zarda / Pan Masala) 7 Are you addicted to any substance? If so, give details. 8 Can you walk 1 km without any support? If NO, give details. 9 Are you physically /visually disabled? If so, give details Duration

Note: Please read the rules and regulations by visiting our website: www.jindalnaturecure.org before submitting this application.

Send reservation deposit equivalent to 3 days accommodation charges of your choice along with the application by DD in favor of JINDAL NATURECURE INSTITUTE, payable at BANGALORE.
If you are coming with a co-patient, please send separate application along with the deposit. For Deluxe Nest & Regular Nest booking at least 2 patients are required. Foreigner/NRI are eligible to apply for Executive Room & above only. The Institute is not liable if you do not read the rules and regulations

Please use the following link to make online payment: http://www.jindalnaturecure.org/onlinepayment.asp For further information please visit our website http://www.jindalnaturecure.org