THE  NEW  INDIA  ASSURANCE  COMPANY  LIMITED
DIVISIONAL  OFFICE - 712500
 Allied Mount Casa Blanca Building, 2nd Floor, 260 Anna Salai, CHENNAI-600 006.
                   Phone  044-852 2886, 044-852 3347    Fax : 044-858 6565  Email : nia25@vsnl.com

                          COMPLETELY TO BE FILLED IN BY THE DOCTOR

 1. Name of the Patient          

                             Age     

 2. Date of Admission                               

     Date of Discharge                                

 3. Name of Surgeon / Physician                    

 4. Diagnosis                                         

 5. Date of first consultation
     (Prior to hospitalization)

 6.  (a) With what complaints was the       
            Patient admitted for :

      (b) Since when was the patient
           suffering from the said complaints

 7. Past History of the Patient (if any)                 
     with  the duration of illness                          

 8. Whether the present ailment is a
      complication of Pre-existing disease ?

     If yes, please, specify the disease 
     (or) Complication of any previous Surgery done ?
     If yes, please specify details.

 9.  Whether the disease/disorder is
       congenital in nature ?

 10.   Nature of Surgery/treatment given
         for the present ailment.

 11.  (a)  Whether Hospital/Nursing Home is
               Registered, if yes, Regn. No.

        (b)    No. of in-patient beds in the Hospital
              (including ICU)

        ( c)  Whether the hospital is having fully equipped
                Operation Theatre of its own/qualified nurses
                Round the clock / Qualified doctors round the
                Clock ?

Signature of the Doctor with seal

Date :

(Note Xerox copies of this format may be used if there is more than one hospitalization)