OM Medicentre Private Limited

  • STAR HOSPITAL (A UNIT OF OM MEDICENTRE PRIVATE LIMITED)
  • +91-7073474757
  • admin@starhospital.co.in
  • Whatsapp
Facebook Instagram Youtube
OM Medicentre Private Limited > 3-General Patient Enquiry

3-General Patient Enquiry

    General Patient Enquiry
    1. Ref. No. Ref. No./MEM/2022/ Date of Enquiry
    2. Name of Family Head / Guardian Name of Patient
    3. Address
    4. Contact number Email ID
    5. Aadhra Card No. PAN number
    6. Votar ID card No.  
    7. Diseases History (in short)
    8. Case Type Select Consultant
    9. Patient Category Occupation
    10. Hospital Membership  
    11.
    Public Adminstrative Detail
    Name of Village / Society Name of Gram Panchayat / Muncipal
    Ward Number Name of Ward Member / Sarpanch
    Contact Number Email ID
    12.
    Contact Detail (Organisation)
    Type of Organisation Name of Organisation
    Contact Person Designation
    Department Contact Number
    Contact Email Id Website
    Type of Panel Panel / Insaurance
    Employee Card Number Policy No.
    Policy Sum-Assured Policy Validity
    13.
    Remarks
    14.
    Name of Lead Provider Name of PRO

    Submitted by:
    Contact Name
    Mobile Number
    E-mail ID
    loader