NIRADHAR SEVA SADAN FOUNDATION

OMKAR ROW HOUSE NO. 8 CHS PLOT NO .5.6.7.8 1. OPP KRISHNA VANDANA CHS USALI ROAD VICHUMBE NEW PANVEL 410206.
East NEW MUMBAI DISTRICT RAIGAD MAHARASHTRA

Regd. No. CIN - U85300MH2022NPL378179
PAN No - AAICN1169Q , 12A - AAICN1169QE20218 , 80G - AAICN1169QF20224 , CSR - CSR00024120

Contact No.: +91 7309211129 | +91 8422800171

WhatsApp No.: 918422800171 Email: niradharsevasadanfoundation@gmail.com

Patient Admission Application Form

We welcome you to apply for patient admission at Niradhar Seva Sadan Foundation. Kindly fill up the following details.

Patient Name*

Phone*

Address*

Diseases / Medical Condition*

Patient Photo (max file size : 2mb)

Age*

Preferable Admission Date

Guardian Name

Gender*

Rental Type*

Declaration

I declare that all the information provided by me in this patient admission application form is true, complete, and accurate to the best of my knowledge and belief.
I understand that the admission is subject to approval by the management of Niradhar Seva Sadan Foundation and availability of space.
I agree to comply with all rules, regulations, and guidelines of the organization during the patient's stay.
I understand that any false information may result in cancellation of admission and I will be solely responsible for the consequences.
I agree to pay the rental charges as per the selected rental type and understand the inclusions and exclusions mentioned.

I have read and understood all the above rules and I am submitting this application on my own responsibility. No one has pressured me mentally or physically.