SMILE Foundation

Application for Financial Assistance for Medical Treatment

Medical Assistance Form

Name of the Applicant (Mr./Mrs.)* :

Name of the Patient (Mr./Mrs.)* :

Age* :

Years* :

Months* :

Gender* :

Male

Female

Pan Card No. of the Applicant / Patient* :

Aadhar Card No.* :

Patients relationship to the applicant* :

Address

Permanent Address* :

Correspondence Address* :

Contact Details :

Phone No.* :

Mobile No.* :

Email* :

Treatment Details (Attach all reports and Doctors certificate)* :

Referred by :

Name and Address of the Hospital :

Name of the Doctor :

Ailment :

Treatment :

Total cost of treatment :

Personal contribution :

Borrowed from relatives and friends :

Total Family income :

Family Details*

Sr. No.	Name of the family members	Relationship to Patient	Age	Occupation	Monthly Income

**Details of Financial assistance sought / received from employer / other trust/ NGO* :**

Sr. No.	Name of the Trust / NGO /Employer	Applied on	Amount received /sanctioned

Any other information* :

I declare that the above facts stated / mentioned and particulars given by me are true and correct.

Date* :

Aadhar Card* :

Pan Card* :

Ration Card* :

Latest income proof of all earning members – Latest Income tax return certificates* :

Applicant Signature* :

Doctor Signature* :

Patient Signature* :

Letter of recommendation if referred for financial assistance other than treating doctor* :

Medical Assistance