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27 views1 page

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Sanjay Gandhi Post Graduate Institute of Medical Sciences

Raebareli Road, Lucknow - 226 014 ,India

ONLINE REGISTRATION FORM

Reference No. REGOL-484011 Ref.Date Jan 28, 2024 Department Endocrinology


Name Ms Anshika Singh

Sex FEMALE Marital Status Single


Date of Birth Apr 19, 2005 Age 18 Yrs Email [email protected]

Religion Hindu Occupation Student Mobile 8172929711

Address(Permanent) Rural Address(Correspondence) Urban

House No House No

Street/ Village Street/ Village

Locality/P.O Jagatpur Locality/P.O Salon Road Jagatpur, Raebareli

City/ District Raebareli City/ District Raebareli

State Uttar Pradesh State Uttar Pradesh

Pin Pin

Phones Phones

Nearest Rly. Stn. Lakshmanpur Nearest Rly. Stn. Lakshmanpur

Emergency Contact Ajay Singh Relationship Father Emergency Phone 9506096141


Ref. Doctor Dr, Manoj Ref. Hospital Mehrotra Clinic Ref. Department Endocrinology
Mehrotra
Identity Type Adhar Card Identity No 833352389265 Issuing Authority Unique Identification Authority Of
India

Please report to the online registration counter before 10.00 AM with your referral documents with this online registration
form.This is valid upto Tue Feb 27 2024 only
1. I/My patient am/is fully aware that this registration is only for O.P.D consultation and this does not qualify for admission
in Emergency Ward.
2. Report to the Reception Counter with this form duly filled along with referral documents and investigation report before 12:
00 noon.
3. In all those departments where no of registration is limited,it may not possible that the patient will be seen on that day.
However ,the patient will be given next possible O.P.D appointment date.

Signature of Patient/Relative

Printed on 28-1-2024 18:24:38 null@null Page 1 / 1

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