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    MedicalAcceptanceCard (1)

    Uploaded by

    johnkiki4545

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    MedicalAcceptanceCard (1)

    Uploaded by

    johnkiki4545
    13 views1 page

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views1 page

    MedicalAcceptanceCard (1)

    Uploaded by

    johnkiki4545

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    H.P. Cal.

    -6/92/1,00,000 ESIC-MED-7B

    MEDICAL ACCEPTANCE CARD

    ASHIM DAS
    Full Name ...................................................................................................................
    BHUT NATH DAS
    Father or Husband's Name .......................................................................................

    VIVEKANANDA MISSION SCHOOL


    Factory Name .............................................................................................................

    Present Residential address

    62 DHALI PARA ROAD PARNASREE PALLY,KOL - 60,Dist:South 24 Parganas,West Bengal,700060,,

    Ins. No./
    4115924047
    Ref. No.

    EMPLOYEES' STATE INSURANCE CORPORATION

    I apply to be included in the list of Dr.........................................................


    I declare that I am not already in the list of a doctor in this or any other
    area.

    Signature or thumb impression of


    Date............................
    Insured Person

    To be completed by Doctor: Doctor's


    Code No.

    I accept this person for inclusion in my list

    Date: Signature of the Doctor.

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