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My Dashboard
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(Regd. under The Bombay Public Trusts Act, 1950)
Date:
To,
The Managing Trustee
Mukul Madhav Foundation
"Harmony", 5 ICS Colony
University Road, Pune 411 007
Tel : 020-25534417, Fax : 020-25534075
Subject:- Request tor Medical Assistance
Photo
(Not Complusary)
Name of the Patient
Age
Name of Applicant
Relationship with Patient
Permanent Postal Address
Mobile No.
Landline with STD code:
Diagnosis
Name of the Hospital
City
Name of the Doctor
Approximate expenses for Treatment / Surgery
Amount collected by Patient
Concession given by Hospital
Family Background
Name of the Signatory
Sugnature
Required Documents: • Estimated cost of the treatment / Surgery as certified by the Hospital • Ration Card Copy • Income Proof
Note: • Age limit upto 25 years • Trust will issue the cheque in the name of the Hospital • Visiting Hours: 10am to 5pm (Sunday off)
(This form is to be filled in by the Patients Relatives)