JINDAL NATURECURE INSTITUTE
JINDAL NAGAR, TUMKUR ROAD, BANGALORE 560073
APPLICATION FORM
Personal Details
Patient’s Name:
Co-patient’s name if accompanied
(Submit a separate application)
Relationship with Co-Patient
Gender
Date of Birth
Age
Marital status
Father / Husband’s name
Full Postal Address
Pin code
Telephone / Mobile
Fax
E-mail
Occupation
Country
Nationality
Passport Details
Passport No.
Date of Issue
Place of Issue
Mandatory as per Immigration Rule :
Domestic patients must present their Photo ID in Original, without which admission may be denied.
Browse Tariff Table
Accommodation Details
Type of Accommodation desired
Total number of days desired
Date from which accommodation Required
Alternate Date from
Details of Reservation Deposit
Annual Income from all sources (In case of Free Ward)
Check In :
Check In:
Check Out :
Check Out:
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 (What are your medical complaints?)
Details
Duration
1
2
3
4
Please answer the following:
1
Have you undergone any operation within 6 months? (Yes / No)
If yes, give details:
2
3
4
5
6
7
8
Do you suffer for any type of Hernia? (Yes / No)
If yes, give details.
Do you suffer from any kind of skin disease? (Yes / No)
If yes, give details
Have you suffered from Heart ailment in the past? (Yes / No)
If yes, give details.
What medicines are you taking at present?
Are you addicted to any substance? Tea / Coffee / Smoking/Alcohol / Drug
addiction / Zarda / Pan Masala
If so, give details
Can you walk 1 km without any support? (Yes / No)
If No, give details
Are you physically /visually disabled in any way ? (Yes / No)
If so, give details
Note: Please read the rules and regulations by visiting our website: www.jindalnaturecure.org before submitting this application.
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.aspx
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.