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Registration

The document is a registration form for Mr. Nishanta Panda, a 22-year-old male from Bhubaneswar, Odisha, India. It includes personal details such as contact information and emergency contact, but lacks specific case type and marital status. The form was prepared by Anshuman Dash on 11/02/2025.

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tusarkant2005
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37 views1 page

Registration

The document is a registration form for Mr. Nishanta Panda, a 22-year-old male from Bhubaneswar, Odisha, India. It includes personal details such as contact information and emergency contact, but lacks specific case type and marital status. The form was prepared by Anshuman Dash on 11/02/2025.

Uploaded by

tusarkant2005
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Registration Form

Print Date/Time : 11/02/2025 12:42 AM


PIN : KIMS12504110004 Registration date : 11/02/2025
Name : Mr NISHANTA PANDA Age : 22/Y Current report
Gender : MALE Religion : item is not
supported in this
Nationality : Case Type :
report format.
Marital Status :
Occupation :

Address : BHUBANESWAR, ODISHA @Mail :


Po Box : City : BHUBANESWAR
Tel. No : Country : INDIA
Off. tel : Pat Income :
Patient ID : No of Members :
Mobile No : 9348678818 Doctor :
Identity : Emergency

LOCAL CONTACT PERSON IN EMERGENCY


Name : SELF
Relationship : Self Email id :
Tel. no : 00 Mobile No. :

Signature of patient/next of kin

Prepared By ANSHUMAN DASH, 209076 Prepared On 11/02/2025 00:42


Generated By Generated On 11/02/2025 00:42
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