Fatima Hospital, Lucknow

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New Patient Registration

Hospital with a difference“We treat God heals”

Registration No.
Patient Name
Age
Sex	Male Female Other
W/o, S/o, D/o
Father's In Law
Address
Village/Local/Area
City
District
Police Station
Post Offce
Nationality
Religion	Christian Hindu Muslim Sikh Other
Contact No.
Department	Medical Paedietrics Surgical Obst Pregnancy Gynae General
E-mail Address
Loan Amout

Note* - Valid for 3 Days Only.
I here by give my consent for tratment in Fatima Hospital for all OPD Consultation Procedure and Investigation.

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