Thanks for filling out MEDICA : PATIENT REGISTRATION FORM

Here's what we got from you:

MEDICA : PATIENT REGISTRATION

FORM
Medica Wishes years and years of Good Health

Email address *

biswajit.datta.durgapur@gmail.com

Are You Medica Registered Patient *

Yes
No
Enter Your Details

Title : *

Mrs.
First Name : *
Write your Name in Uppercase

SHAMPA

Last Name : *

DATTA

Sex : *

Female
Male
Transgender
Nationality *

Indian
Father's/Husband's Name: *
Write your Full Name in Uppercase

BISWAJIT DATTA

Marital Status : *

Married
Date of Birth : *
MM

05

DD

19

YYYY

1972

Patient Address : *

116 NSC BOSE ROAD, RANIKUTHI

Locality *

RANIKUTHI

City *

Kolkata
Pin Code: *

700040

Police Station : *

REGENT PARK

Enter Your ID Card Details

Aadhar Number *

494852213582

Upload Photo Copy of Aadhar Card *

Submitted files

Shampa Datta - Biswajit Datta.pdf

Enter Your Payment Details

Click and Pay ( Vaccination Charges Rs.250 ) Upload (Take Screenshot) of Your
Payment Receipt *
Click this link for online payment to Medica Hospital : Payu Money : -
https://www.payumoney.com/pay/#/merchant/027486BF922B5FFB426FE908F82C0896?param=6778874

Submitted files

Shampa Datta - Biswajit Datta.pdf

I would like to receive SMS from Medica about camps and discounted schemes. *

Yes
Enter Your Mobile No. *

9163365246

Signature of Patient / Relative

Signature :

MHPL/REG/001/001