Registration Details

Registration No. 2017100829790 Date Of Registration 08/10/2017

Identi cation Details

*First Middle *Last

Initial  Mr KAILASH NATH
Name  Name  Name 

Personal Information

*DOB 01/01/1964 * Age at Registration 53 Years  9 Months

*Sex Male Marital Status MARRIED

Father/Spouse's Name *Education LITERATE

Occupation BUSINESS Family Income Monthly (Rs.)

*Nationality INDIAN Pan No. AKHPN1102F

*Religion HINDU

*Mother Tongue HINDI

Aadhaar Number 858710880981

Referral Information

Referred By Doctor/Hospital Clinic Dr D S YADAV Address of Referring Doctor/Hospital Clinic SAMUDAIC SWASTH KENDRA S

Referred For TREATMENT

Permanent Address

*Country INDIA State UTTAR PRADESH

SRIRAMPUR ROAD, SHAHGANJ,

District JAUNPUR *Address DIST: JAUNPUR

City/Town/Village JAUNPUR Pin Code 223101

Country Code  STD Code    Number

Telephone No. Mobile No. 8090613970

*E-mail Id satishkumarshg@gmail.com Re-con rm E-mail Id satishkumarshg@gmail.com

Country Code  STD Code    Number

Fax No. Resident of Mumbai (More than 1 Year)

Address for Correspondence

*Country INDIA State UTTAR PRADESH

SRIRAMPUR ROAD, SHAHGANJ,

District JAUNPUR *Address DIST: JAUNPUR

City/Town/Village JAUNPUR Pin Code 223101

 Country Code  STD Code    Number
Telephone No. Mobile No. 8090613970

Country Code  STD Code    Number

Fax No.

Kin's Details

Name SATISH KUMAR AGRAHA Relationship with Patient SON

Country Code  STD Code      Number

Country INDIA Fax No.

State UTTAR PRADESH

SRIRAMPUR ROAD, SHAHGANJ,

District JAUNPUR Address DIST: JAUNPUR

City/Town/ Village JAUNPUR Pin Code 223101

Country Code  STD Code    Number

Telephone No. Mobile No. 8090613970

E-mail Id satishkumarshg@gmail.com Re-con rm E-mail Id satishkumarshg@gmail.com

Medical Insurance

Yes      No   

Travel Concession

  Railway (Station)   Air (Airport)

  Road (Terminus) *Identi cation Mark1 CUT MARK ON HEAD

Identi cation Mark2 Anticipated Date of Visit to TMH 09/10/2017

    Patient's/Attendant's Signature : _________________________________