GRIEVANCE

Patient Details
Employee/Pensioner*: Employee Pensioner
Health Card No*: /
First Name*: Last Name:
Age: Gender: Male Female
Contact No*: Email:
House No: Street:
State*: District*:
Mandal/Muncipality: Mandal Municipality Mandals/Municipalities:
Villages/Cities/Towns:

Grievance Details
Hospital Details
State: District:
Hospital:
Grievance Against
Designation*: Name*:
Grievance Details
Nature of Grievance*: Category:
SubCategory: Surgery:
Templates*: Attachment:
(Maximum size - 200 KB)
Grievance Description*: