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Mob No.
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Occupation
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Date of Birth
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Aadhar No.
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Blood Group
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AB+
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B-
O-
Not Known
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Covid Status
(Whether suffered from covid)
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Yes
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Comorbidities
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Hypertension
Diabetes
Heart Disease
Lung - Lever and kidney disease
Cancer patients
Transplant receiptant
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Other Comorbidities
(If not in above list)
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Note : Fields prefixed with * must be compulsorily filled, others are optional.
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Applicant Name
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Mob No.
*
Maritial Status
Select status
UnMarried
Married
*
Designation
CGHS No.
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Section/Dept
*
Date of Birth
*
Aadhar No.
Email ID
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Blood Group
A+
B+
O+
AB+
AB-
A-
B-
O-
Not Known
*
Covid Status
(Whether suffered from covid)
No
Yes
*
Comorbidities
Not Applicable
Hypertension
Diabetes
Heart Disease
Lung - Lever and kidney disease
Cancer patients
Transplant receiptant
Other chronic disease
Other Comorbidities
(If not in above list)
*
Address Type
President's Estate Pool of accomodation
Other
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