AMRQH Medical Tourism Structure With Allied Hospitals And Medical Centers (National/International)

Name (in capital):

Address (permanent):

Address (correspondence):

Date of Birth:

Daughter/Son/Spouse of:

Phone Number:

Email:

Country:

City:

Nationality:

Caste:

Gender:

Occupation:

Marital Status:

Photo (JPEG or PNG only):

Program Name:

Type of Medical Tourism you want to choose:

Identity Proof (PAN Card, Driving License, Voter ID Card)(JPEG or PNG only):

Residential Proof (Aadhar Card)(JPEG or PNG only):

SELECT PAYMENT MODE:

1. FAST PAY SERVICE:
ONE TIMEINSTALMENT BY MONTHLYINSTALMENT BY WEEKLY

2. BELOW POVERTY LAUGHTER:

3. GO-BUSINESS BLUE:

WHY I WANT TO PURSUE THIS PROGRAM?

DECLARATION

I, SRI/SMTI SON/DAUGHTER OF/ SPOUSE OF declare that the information given in this application is true and correct to the best of my knowledge and belief. I am pursuing this program with all my consent and no one is liable for this but me. And also I hereby declare that I will abide by all the rules and regulations of this Hospital whatever provided during the program. In case any information given in this application proves to be false or incorrect and if I will violate any sort of rules and regulations of this Hospital during their observations then I shall be liable by the law of jurisdiction and take all responsibilities for the consequences.

PLACE:

DATE:

(SIGNATURE)

(GUARDIAN SIGNATURE)

I, hereby, confirm that I have carefully read and fully understood the Terms and Conditions governing the use of (service/product), and I hereby accept and agree to be bound by all of its provisions.

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