Patient Form Patient's Information :Full Name *Date of Birth *Father's Name *Mother's NameStreet Address *DistrictPincodePhone Number *Condition of the Patient : *0 / 30Name of Hospital Where Patient is Admit *Kindly specify your relationship to the patient : *I am the patientI am a relative of the patientRelative's Information :Full Name *Mention Your Relation to the Patient (e.g., Father, Spouse..) *Father's Name *Mother's NameStreet Address *DistrictPincodePhone Number *Documents Required :Please upload copy of your Aadhar Card (Both Sides) in one PDF or Image.Choose FileNo file chosenDelete uploaded fileUpload copy of Patient's Family Member's or Relative's Aadhar Card.Choose FileNo file chosenDelete uploaded fileSignature *Start signing your signature hereYour browser does not support e-Signature field.Terms And Conditions :Yes, I agree with the statement that the treatment of the patient mentioned in the above form is currently ongoing at the hospital (name also mentioned in the form). The father's name of the patient has also been provided in the form. The doctor has informed both the patient and the patient’s family about the condition of the patient and advised to appoint a caretaker for their care. I am appointing a male/female caretaker (experienced staff) from the company "Sehnaaz Home Care," Bathinda. In case any emergency arises at home with the patient, the company or staff will not be held responsible. I will be solely responsible. All the details mentioned in the form are correct, and I take full responsibility for them.Yes, I agree i have carefully read and understood the privacy policy and terms and conditions of the company, and I am appointing the staff from "Sehnaaz Home Care," Bathinda for the care of the patient.Submit