Lab Discount Form

Patient Name

Aadhar Number of Patient

Mobile Number of Patient

Care Taker Number

Your email ID

District
AlappuzhaErnakulamIdukkiKannurKasargodKollamKottayamKozhikodeMalappuramPalakkadPathanamthittaThiruvananthapuramThrissurWayanad

PRESENT ADDRESS

PERMANENT ADDRESS

You are a
Tx (TRANSPLANT PATIENT)Di (DIALYSIS PATIENT)Do (Donor)

Name of the Hospital

Hospital ID Number

Donor Name and Relationship

Date of Transplant (DD/MM/YYYY)

Upload Doctor Letter

Upload Aadhaar Card

I confirm that the above information provided by me are True and Correct
YesNo