JINDAL NATURECURE INSTITUTE
A Charitable Hospital
Jindal Nagar, Tumkur Road, Bangalore-560073
Phone
: 080-23717777 (4Lines),
Mobile
: 9611195458
Fax
: 080-28374806
Website : http://www.jindalnaturecure.org
E-mail
: res@indalnaturecure.org
NEW ADMISSION
RE-ADMISSION
FOREIGNER / NRI
APPLICATION FOR ADMISSION FOR CANCER TREATMENT
(PLEASE WRITE IN BLOCK LETTERS)
PLEASE FILL ALL COLUMNS ON BOTH SIDES TO AVOID DELAY IN PROCESSING.
Application will not be processed, if not submitted with Reservation Deposit.
For rules, regulations and room tariff please refer information Brochure/Website.
Name:……………………………………………………………………..... Male
Female
Age:….........Date of Birth……………………...Father’s/Husband’s Name………………………………….
Full Address ……………………………………………………………………………...................................
…………………………………………………………………………………………………………………
……………………………………………………………………………….Pin code……………………….
Telephone/Mobile……………………..Fax……………………Local contact phone if any………………....
Occupation……………………………………………Married/Unmarried…………………………………...
Nationality……………………………. e-mail ID…………………………………………………………….
FOR FOREIGN NATIONALITY/NON RESIDENT INDIANS
Passport No……………………………..Date of issue………………….Place of issue……………………...
Accommodation required: Please number the boxes in order of preference, say 1,2,3
Cottage
Suite Accommodation
Hut-FF
Hut-GF
Nest
Dlx.Hut
Deluxe Accom
Dlx.Nest
(For Deluxe Nest & Nest booking at least 2 patients are required
Accommodation required from…………………………………..To…………………………........................
Alternative date from……………………………………………To………………………………………….
Bank Draft No…………………………...Rs……………….....enclosed towards 3 days Reservation Deposit
Incase of readmission, please write:
Previous Date of Admission………………...M.R.No…………………Ward………………………………..
Personal History: (Please give specific information)
1. Height……………………… 2. Weight……………………….. 3. Blood Pressure……………………….
4. Appetite……………………. 5. Sleep…………………………. 6. Urination……………………………..
7. Bowels……………………... 8. Incase of female, Menstrual cycle………………………………………..
Please give details of your case:
1. Cancer effected of part ………………………………………….. When was it detected .………………..
2. What is the stage ……..…………………Any metastasis was detected? Yes /No ...………………………
3. Present symptoms …………………………………………………………………………………………..
4. Present line of treatment / medicines being used …………………………………………………………..
5. Did you under go Surgery /Radiation / Chemotherapy give details ………………………………………..
6. If so when? ……………………………………………..Where? / By whom?
(Give the name of the hospital & the name of the doctor)………………………………………………….
7. Do you suffer from any other problem ……………………………………………………………………..
If so, please give the details ………………...……........................................................................................
Please answer the following:
1. Have you undergone any operation within 6 months? Yes / No.
If yes, give details (Enclose copy of the report)_________________________________________
2. Do you suffer from any type of Hernia? Yes / No._______________________________________
3. Do you suffer from any skin disease? Yes / No._________________________________________
4. Have you suffered from Heart ailment in the past? Yes / No.
If yes, give details ________________________________________________________________
5. What medicines are you taking at present? ____________________________________________
6. Are you addicted to any substance? Tea/Coffee/Smoking/Alcohol/Zarda/Pan Masala
7. Can you walk 1 Km without any support? Yes / No.
If no, give details ________________________________________________________________
8. Are you physically / visually disabled in any way? Yes / No
If so, give details: ________________________________________________________________
Please enclose copies of recent medical records related to Cancer and Other problems
(Please do not send any film)
CONDITIONS:
1. The Management reserves the right of admission and
discharges any patient at any time without assigning
any reason whatsoever.
2. Patients are not allowed to go out during their stay,
like any other hospital. Outside food is strictly
prohibited.
3. Smoking or taking tea, coffee, alcohol, zarda/pan are
not allowed in the campus. Also please abstain from
taking such items at home atleast 7 days before
admission for better result.
4. The extension of stay can be considered only on the
advice of our doctors and on availability of
accommodation.
5. Patients are advised to bring all the medicines
which their doctor prescribed for the scrutiny of
our consultants.
6. As success of treatment will soley depend on the
patients strictly adhering to the discipline in the
prescribed diet, Naturopathic treatments & yoga, no
assurance about cure/recovery can be given.
7. Three clear days notice is required (excluding the
date of admission) in writing for postponements /
cancellation of confirmed admission date. In case of
of 2 days notice 50% of the deposit will be forfeited and if
the notice is less than 2 days 100% will be forfeited.
8. Admission will not be given and deposit will be
forfeited if any medical information is concealed or
wrong information given in the application form.
9. Tariffs are subject to change without prior notice
prevailing rates at the time of stay will be charged.
UNDERTAKING:
I have read the conditions mentioned above and also those
mentioned in the Brochure, all of which I heartily accept,
and solemnly undertake that I shall abide by the rules and
conventions of JNI faithfully. Also, nature of treatment at
the institute and the possible benefits and risks are
understood by me. I opt for treatment on my own accord.
In the event of complications and / or adverse
reactions arising during my stay at JNI the
management will not be held responsible and it has the
right to shift/refer me to a suitable medical institution
for necessary treatment, at my cost risk and
responsibility.
Date:
Signature of Patient
FOR OFFICE USE ONLY
Regd.on……………………….Cash Receipt No…………………Rs…………………….Date……………..
MEDICAL OFFICER
Cancer Care at Jindal Nature cure Institute:
In recent times, we received a large number of requests to launch complimentary treatments
for patients suffering from cancer, and in response, JNI Management is pleased to announce
that in a limited scale, JNI will admit patients who are suffering from cancer in Stage I & Stage
II. However, since the patients will require, among other special treatments, committed,
personalized attention, they will not be admitted to accommodation below a Cottage. Further,
a patient must be ready to stay for a minimum period of 30 to 40 days and at times, even
longer, as per doctor’s advice. Also, it is imperative for the patient to note that nature cure
requires a patient’s total faith in the system and perseverance. Hence, those who fulfill these
criteria shall only seek admission.
The treatment of Cancer patients to be followed here will be complimentary, and not a
replacement of the treatment they are already receiving which may include Chemotherapy,
Radiotherapy and Medicine etc. In fact, there are numbers of nature cure hospitals in USA,
Canada & UK who are specialized in Naturopathy Oncology and are doing wonders in the curing
of cancer. As such the concept of complimentary treatment in cancer cure involving
naturopathy, natural medicine and diet is now universally accepted, and we are in touch with
Naturopath Oncologists as well as Universities for collaboration and are trying to adopt their
philosophy.
Those desirous of getting admitted may please send details about their ailment to the Institute
for further processing.