Groctt Aasict MEOI ASSIST NDIA TPA PRVATE TO. 1449, “Shipa Vidya” Buildings, 1. Main, Saraki Industral Layout, 3. Phase J..Nagar, Bangalore - 960076, Phone: 26584841 F "28538703 Toll Free: 1800 4250 440, MEDICAL CERTIFICATE TO BE FILLED IN BY THE DOCOTR TREATING THE PATIENT Please Do not put ‘Dots’ (.) Or Dashes (.) 1_[ Name ofthe Patient Age [| _Yis Hospitalsation mission 2 | pera [Bat ot admis Date of Discharge Diagnosis 3 4 | Date of First Consultation (Prior to Hospitalisation) '5_| Presenting Complaints on admission ¢g_| Since when was the patient suffering frm these? 7 | Pasthistoy of the patent, any, with duraton of ailments Whether the present aimentis a complication of any| 7 8 | Pre-existing aiment? x Ne | yes, please spect the disease or complication of ‘any previous surgery done and detais thereof to | Wier Dost! Dtec Daoderi ongeta Ta w “i_| Nature of treatment given or surgery performed for the present ailment! injury ‘2. Ifthe claim is for maternity, numberof Wving chien ‘excluding the new born ‘Whether the hospital i registered with the Local 8 please furnish Registration 14. | Number of inpatient beds in the Hospital 45_ | Whether the hospital has fully equipped Operation ‘Theate of ts own? 16. | Whether qualified Nurses are employed round the cock? “17, | Whether the Hospital is under the supervision of a Registered Medical Practioner round the clock? ye. | Name of the 18ers tor Quatifcaton “Telephone No} Date: Signature of the Doctor with Seal