Institute Of Naturopathy & Yogic Sciences, Bangalore, India

JINDAL NATURECURE INSTITUTE JINDAL NAGAR, TUMKUR ROAD, BANGALORE 560073 APPLICATION FORM

Personal Details Patient’s Name: Co-patient’s name if accompanied (Submit a separate application) Relationship with Co-Patient Gender Date of Birth Age Marital status Father / Husband’s name Full Postal Address Pin code Telephone / Mobile Fax E-mail Occupation Married / Unmarried Country Nationality Passport Details Passport No. Date of Issue Place of Issue

Accommodation Details Browse Tariff Table Type of Accommodation desired

Total number of days desired Date from which accommodation Required From : To : Alternate Date from From : To : Details of Reservation Deposit Annual Income from all sources (In case of Free Ward) In case of re-admission, please write Previous date of admission: M.R. Number: Accommodation: Personal History Height Weight BP Appetite Sleep Urination Bowels Menstrual Cycle

Disease particulars (What are your medical complaints?) Details Duration 1 2 3 4 Please answer the following: 1 Have you undergone any operation within 6 months? (Yes / No) If yes, give details: 2 Do you suffer for any type of Hernia? (Yes / No) If yes, give details. 3 Do you suffer from any kind of skin disease? (Yes / No) If yes, give details 4 Have you suffered from Heart ailment in the past? (Yes / No) If yes, give details. 5 What medicines are you taking at present? 6 Are you addicted to any substance? Tea / Coffee / Smoking/Alcohol / Drug addiction / Zarda / Pan Masala If so, give details 7 Can you walk 1 km without any support? (Yes / No) If No, give details 8 Are you physically /visually disabled in any way ? (Yes / No) If so, give details Note: Please read the rules and regulations by visiting our website: www.jindalnaturecure.org before submitting this application. The Institute is not liable if you do not read the rules and regulations Please use the following link to make online payment: http://www.jindalnaturecure.org/onlinepayment.aspx Send reservation deposit equivalent to 3 days accommodation charges of your choice along with the application by DD in favor of JINDAL NATURECURE INSTITUTE, payable at BANGALORE. If you are coming with a co-patient, please send separate application along with the deposit. For Deluxe Nest & Regular Nest booking at least 2 patients are required. Foreigner/NRI are eligible to apply for Executive Room & above only.