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APPLICATION
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Patient Photo
(jpg,jpeg and max 2mb
NAME AND ADDRESS OF PATIENT
Male
Female
PERSONAL INFORMATION
TELL US THE NAMES OF ALL MEMBERS OF THE FAMILY
First Name
Last name
Relationship to patient
Occupation
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DETAILS OF YOUR MONTHLY INCOME
Please include all earnings from jobs (after deduction of income tax), benefits and allowances including DLA etc. for ALL members of the household. Please ensure that this section is correctly completed; failure to do so will result in your application being rejected.
Source
Amount
MEDICAL INFORMATION
(haemodialysis / CAPD / kidney transplant / pre-dialysis / other (state)):
Medical Certificate
(jpg,jpeg and max 2mb)
DECLARATION BY PATIENT (OR PARENT/GUARDIAN)
Signature
(jpg,jpeg and max 2mb)
DECLARATION BY PANCHAYATH /CORPORATION / MUNICIPALITY
Upload Declaration Certificate From Panchayath /Corporation/municipality
&nbp;(jpg,jpeg and max 2mb)
I accept the
terms & conditions
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Final Submit