ASILO NORTH DISTRICT HOSPITAL MAPUSA GOA

PEDDEM, MAPUSA GOA 403507, , INDIA

ASILO NORTH PHONE
DISTRICT HOSPITAL MAPUSA GOA
:9999999999
PEDDEM, MAPUSA GOA 403507, , INDIA
PHONE :9999999999
ADMISSION CARD PRINT DATE: 03-Jul-2022
CR No : 100012200000086 IPD No : 100012022000018
ADMISSION PRINT DATE: 03-
CARD Jul-2022
CR No IPD No
NAME : : 100012200000086
First : 100012022000018
AGE/GENDER : 23 Yr/M
FATHER/SPOUSE : /- MARITAL STATUS : --
CATEGORY : General MLC NO : NA
ADMISSION :  0
NAME : First AGE/GENDER : 23
CHARGES
Yr/M
DEPARTMENT/UNIT : Orthopaedics/Orthopedic Department 6
FATHER/SPOUSE
: /- MARITAL : --
WARD/BED : Male Female Surgical/ STATUS
CONSULTANT : Duty Doctor:
CATEGORY General MLC NO : NA
ADDRESS : Adasd 23, rrt,
ADMISSION : South
 0Goa, Goa, India ,PH NO:6854684568 ,MOB NO:6854684568
CHARGES
EMG CONTACT : DEPARTMENT/UNIT
: Orthopaedics/Orthopedic Department 6
ADM DATE : 03-JUL-2022/22:46:00
WARD/BED : DISCHARGE DATE
Male Female Surgical/ :

CONSULTANT
: Duty Doctor
FOR MEDICO LEGAL PURPOSE
ADDRESS : Adasd 23, rrt, South Goa, Goa, India ,PH
DETAILS OF POLICE STATION -- POLICE INFORMATION --
NO:6854684568 ,MOB NO:6854684568
NAME OF INFORMANT -- IDENTIFICATION MARKS --
MLC REMARKS --
EMG :
CONTACT
PROV DIAGNOSIS ADM : 03- DISCHARGE :
DIFF DIAGNOSIS DATE JUL-2022/22:46:00DATE
FINAL DIAGNOSIS
FOR MEDICO LEGAL PURPOSE
NAME & SIGNATURE OF MO DETAILS OF POLICE -- POLICE& SIGNATURE OF --
NAME CONSULTANT
DATE & TIME STATION INFORMATION
DATE & TIME
NAME OF -- IDENTIFICATION --
INFORMANT MARKS
MLC -- ASILO NORTH DISTRICT HOSPITAL MAPUSA GOA
REMARKS PEDDEM, MAPUSA GOA 403507, , INDIA
PHONE :9999999999

PROV
NAME : First
DIAGNOSIS AGE/GENDER : 23 Yr/M
IPD NO : 100012022000018
DIFF
DEPARTMENT : DIAGNOSIS
Orthopaedics/Orthopedic Department 6
WARD/BED : FINAL
Male Female Surgical/
DIAGNOSIS
DOCTOR'S NAME : Duty Doctor
ATTENDANT'S :
NAME & SIGNATURE OF MO NAME & SIGNATURE OF
NAME
CONSULTANT
PATIENT ATTENDANT'S ID/AADHAAR CARD NO (LAST 4 DIGITS) :  --
DATE & TIME DATE & TIME
VALID FOR 7 DAYS SIGN. OF ISSUING CLERK

ASILO NORTH DISTRICT HOSPITAL MAPUSA GOA

PEDDEM, MAPUSA GOA 403507, , INDIA
PHONE :9999999999

NAME : First AGE/GENDER : 23

Yr/M
IPD NO : 100012022000018
DEPARTMENT
: Orthopaedics/Orthopedic Department 6
 ASILO NORTH DISTRICT HOSPITAL MAPUSA GOA
PEDDEM, MAPUSA GOA 403507, , INDIA
PHONE :9999999999
ASILO NORTH DISTRICT HOSPITAL MAPUSA GOA
PEDDEM, MAPUSA GOA 403507, , INDIA
PHONE :9999999999
BILLING SERVICES RECEIPT
CR No. : 100012200000086 ADMISSION
DATE&TIME : 03-Jul-2022 PRINT
22:46:00 BILL No. DATE: 03-
: 100014220000034/1
NAME : FIRST
CARD Jul-2022
CATEGORY : GENERAL AGE/SEX : 23 YR/MALE ORG. : ---
SERVICE : IpdCR No WARD IPD:No MALE FEMALE SURGICAL
: 100012200000086 : 100012022000018
----------------------------------------------------------------------------------------------
S.No. PROCEDURE/INV./SERVICE LOCATION RATE(Rs.) QTY. PATIENT AMOUNT(Rs.)
----------------------------------------------------------------------------------------------
1 IPD ADVANCE --- 0.00 1 0.00
------------
TOTAL AMOUNT 0.00
NAME : First AGE/GENDER : 23
------------
RUPEES (IN WORD) : Zero Rupee Only Yr/M
FATHER/SPOUSE
NOTE : AMOUNT,PATIENT :
SHARE AND /-
CREDIT SHARE ARE MARITAL
IN Rs. : --
MODE OF PAYMENT: Cash
STATUS
PAYMENT DETAILS:CASH : (AMT::0.00)
CATEGORY : General MLC NO : NA
ADMIN ASILO (NA)
AUTHORISED SIGNATORY
ADMISSION:  0
CHARGES
DEPARTMENT/UNIT
: Orthopaedics/Orthopedic Department 6
WARD/BED : Male Female Surgical/
CONSULTANT
: Duty Doctor
ADDRESS : Adasd 23, rrt, South Goa, Goa, India ,PH
NO:6854684568 ,MOB NO:6854684568

EMG :
CONTACT
ADM : 03- DISCHARGE :
DATE JUL-2022/22:46:00DATE

FOR MEDICO LEGAL PURPOSE

DETAILS OF POLICE -- POLICE --
STATION INFORMATION
NAME OF -- IDENTIFICATION --
INFORMANT MARKS
MLC --
REMARKS

PROV
DIAGNOSIS
DIFF
DIAGNOSIS
FINAL
DIAGNOSIS

NAME & SIGNATURE OF MO NAME & SIGNATURE OF

CONSULTANT
DATE & TIME DATE & TIME

ASILO NORTH DISTRICT HOSPITAL MAPUSA GOA

PEDDEM, MAPUSA GOA 403507, , INDIA
PHONE :9999999999

NAME : First AGE/GENDER : 23

Yr/M
IPD NO : 100012022000018
DEPARTMENT
: Orthopaedics/Orthopedic Department 6