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PASTE YO UR
(For Leader/ Manager Job Level) RECENT PASSPRT
SIZE PHO TO GRAPH
(Prospectiv e employ ee should fill in Section 1 to 4 (Attested by the
The Examining Medical Officer w ill fill in Section 5 to 6 Examiner)
________________________________________________________________________
Address: ____________________________________________________________
____________________________________________________________________
____________________________________________________________________
City __________________________________________
Pin:_______________
Mother
Brother (No.)
Sister (No.)
Husband/Wife
Children (No.)
Ty pes of Prev ious Occupation (Pl. describe in brief about company , nature of work, duration in y ears)
Name of Candidate: _________________________________________
Y N Y N
Heart disease Hy pertension
4 I declare that the abov e statements are true and complete to the best of my knowledge and
belief and I agree that the results of this medical ex amination in general terms may be
rev ealed to the company if required. I also fully understand that in case I am declared
medically unfit due to any reason, I shall not be entitled for the employ ment in the company .
Howev er, The decision taken by the company 's doctor/s about my medical fitness will be final
and binding to me.
Date (dd/mm/y y y y ) Signature of Prospectiv e Employ ee
(Ex amining doctor should ensure that candidate has filled up section 1 to 4)
BMI
Chest: Ex piration cms Inspiration cms
Name of Candidate: _________________________________________
Ax is
Y es No
Squint
7 Audiometry Report
8 P.F.T Report
Scars _______________________________________________________
Identification marks:
1 _________________________________________________
2 ________________________________________________
14 Nerv ous Sy stem ____________________
Pupilary Reaction ______________________
Apollo clinic, 66 A/2, New Rohtak Road, Karol Rachna Pilani-FO Manager:
Karol bagh, Bagh, New Delhi cc.kbh@apollospectra.com:886024
2 Delhi Delhi NCR
New Delhi 6241
(Apollo Spectra)
5D/ 8A, NIT-5,Railway station Mr.Ram Awadh Singh Mo:
Road,Near Neelam 7309134442
Chowk,Faridabad – 121001. Phone:0129-4150038
The Apollo Email:
3 Faridabad Delhi NCR
clinic, Faridabad fo.faridabad@apolloclinic.com;
ramawadh.singh@apolloclinic.com.
2012, 1st Floor, 100 Feet Road, Center Manager: Ms.Punita Singh -
HAL 2nd stage, Indira Nagar Mo: 8197985985
Phone: (080) 2521 4614/15
Apollo clinic,
8 Bangalore Karnataka Email:
Indiranagar
indiranagar@apolloclinic.com;
punita.singh@apolloclinic.com
Apollo clinc, Sunder Baug, Ujagar Compound, Ms. Pavani Keta: 8655531669
15 Chembur Mumbai Maharashtra Opp. Deonar Bus Depot Main cc.cbr@apollospectra.com
(Apollo Spectra) Gate, Mumbai - 400 088
Centriole, Plot #90, Survey #129, Mr.Ankur Khare Mo: 9689943420
130/1+2, ITI Road, Aundh Phone: (020) 2588 7961 - 4
Email:
Apollo clinic,
16 Pune Maharashtra santosh.shinde@apolloclinic.com,
Aundh
aundh@apolloclinic.com,
ankur.khare@apolloclinic.com
11, First Floor, Gaur Gravity, Plot Mr. Darmendra Rawat, Mo:
No.8, Vaibhav Khand, 9958476660
Indirapuram Phone: (0120) 640 2598/99;
8586999138
The Apollo Email:
31 Gaziabad Uttar Pradesh
clinic, Gaziabad indrapuram@apolloclinic.com;
dharmendra.rawat@apolloclinic.co
m
Mann Complex, Anand Mahal Ms. Sohil Mehsania- CM, Mr. Sonal
Road, Adajan, Surat – 395 009 Tank- Accounts Manager;
Mo 91 9979858877 / 91
9409077009
Phone: 0261 – 279 0202 / 279
5031;
The Apollo Clinic, Email:
4 Surat Gujarat
Surat(Network) adajan@theapolloclinic.com,
apolloclinicsurat@gmail.com;
Clinic Name/
Sl City State Clinic Address Clinic Contact
Location
Apollo Clinic,1, Cosmic Ms. Beena Anand; Mo 91 98370
Enclave,Opposite SBI Bank ( 31808;
Sama Branch),Near GIPCL Phone: 0265-2780040, 2780030
The Apollo Clinic,
Circle, Sama,Vadodara-390008, Email:
5 Vadodara Vadodara Gujarat
vadodara@theapolloclinic.com
(Network)
The Apollo Clinic, The Emerald, Phone: 022 - 2788 1322 - 1325;
Plot No. 195/B, Sector–12 Email: vashi@theapolloclinic.com
Apollo clinic, Besides Neel Siddhi Towers,
9 Mumbai Maharashtra
Vashi (Network) Vashi, Navi Mumbai – 400 703.
Renai Medicity Post Box No. 2259, Mr. Suresh P Asst Manager - M & S
Multi Speciality Mamangalam, Palarivattom. P Dept, Mo: 9388218156;
Hospital O, Cochin, Kerala, India – 682 Mr. Mahesh Raghavan - Corporate
(Pollakhuth 025 Manager - M & S Dept. Mo:
Narayann) 9349212345;
Phone: +91 484 288 0288 / 288
0000;
Email: care@renaimedicity.org;
marketing@renaimedicity.org;
mahesh@renaimedicity.org
37 Kochi Kerala
Amri-Salt Lake, JC -16 & 17, Salt Contact: Gaurab Maiti +91-
Lake City, Kolkata - 700 098 3366147700; 8420223302/
AMRI Hospitals 9831698254
65 Kolkata West Bengal
Salt Lake
Clinic Name/
Sl City State Clinic Address Clinic Contact
Location
127 Mukundapur, E.M. Bypass, Sanjukta Paul: 9230095215;
Kolkata: 700099 Ph:+91 33 66520000,
Email:
contactus@medicahospitals.in;
sanjukta.paul@medicasynergie.in;
Corporate Desk for Medica Kolkata
to facilitate appointments etc –
Medica
09230011834
66 Superspeciality Kolkata West Bengal
Hospital