CHARITABLE TRUST – PATIENT ASSISTANCE FORM

Charitable Trust – Patient Assistance Form

Patient Details

Full Name of the Patient:

Age:

Gender:

Contact Number:

Alternative Contact Number:

Email ID (if any):

Address:(for verification) House No. Street:

City:

State:

Pincode:

Eligible for Zakaat: Yes No

Medical Information

Name of the Disease/Illness:

Date of Diagnosis:

Hospital/Clinic Name:

Hospital/Clinic Address:

Treating Doctor's Name:

Doctor's Contact(if any):

TYPE OF TREATMENT RECOMMNDED: Surgery Chemotherapy Dialysis Medication Other

Estimated Treatment Cost (Attach Estimate/Quotation):

Financial Information

Annual Family Income (for verification):

Occupation of Patient/Guardian:

Is the patient currently employed? Yes No

Other Sources of Income (if any):

Any Previous Financial Aid Received? Yes No

Please Specify Financial Aid Details:

Amount Requested From Trust:

Attachments Required (tick once attached)

TYPE OF TREATMENT RECOMMNDED:

Government ID Proof (Aadhar/PAN/Passport)

Income Certificate / Ration Card

Medical Reports & Prescription

Treatment Estimate from Hospital

Photograph of the Patient

Bank Passbook Copy / Cancelled Cheque

I hereby declare that all the information provided above is true to the best of my knowledge. I understand that submitting false information may lead to disqualification from receiving aid. I authorize the trust to verify all the documents and information provided.