INSTITUTE OF NATUROPATHY & YOGIC SCIENCES, BANGALORE, INDIA

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INSTITUTE OF NATUROPATHY & YOGIC SCIENCES, BANGALORE, INDIA Powered By Docstoc
					                               JINDAL NATURECURE INSTITUTE
                      JINDAL NAGAR, TUMKUR ROAD, BANGALORE 560073
                                    APPLICATION FORM
                                       Personal Details
Patient’s Name:
Co-patient’s name with Relationship if accompanied
           (Submit a separate application)
Gender
Date of Birth
Age
Marital status
Father / Husband’s 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                      Browse Tariff Table
Type of Accommodation desired

Total number of days desired
Date from which accommodation Required                  From :            To :
Alternate Date from                                     From :            To :
Details of Reservation Deposit
Annual Income from all sources (only in case of
Free Ward)
                               In case of re-admission, please write
Previous date of admission         M.R. Number             Accommodation
                                           Personal History
Height Weight BP          Appetite      Sleep        Urination   Bowels          Menstrual Cycle


                                          Disease particulars
                             Details                                               Duration
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
        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

				
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posted:3/28/2012
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