Name of the patient(Mandatory)
Name of Father/Mother/Husband/Guardian (Mandatory)
Email(Mandatory)
Phone Number(Mandatory)
Caste / Tribe
Residential Address(Mandatory)
Gender Male Female
Age (Mandatory)
Nature of disease(Mandatory)
Date of surgery
Name of the Hospital from where treatment is sought
Medical Aid required
Annual income of all adult members of family from all sources
Whether the applicant has taken such assistance from any other sources, if so give details