| Name* : |
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| Age* : |
Years.
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| Sex* : |
|
| Contact No* : |
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| E-Mail* : |
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| Address* : |
|
| Place* : |
|
| State* : |
|
| Country* : |
|
| Date of Surgery* : |
|
| Coming from which place* : |
|
| Mode of Transport* : |
|
| ID Proof* : |
ID No :
|
| |
| Accompanying Person |
| Name* : |
Age* :
Years. Sex* :
|
|
Relation* : |
|
|
|
|
Note* :
1. Free Accommodation for 24 hrs only.
2. Food and other things extra.
* Conditions apply according to the Hotel.
For further details contact
Cell: +91 - 8008445511/22 (VIJAYAWADA)
Cell: +91-8008445533/44 (RAJAHMUNDRY)
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