Registration Form for Patient Funding

Sr.No:______________Date:______________

Part-1 (To be filled by a physician).

01.Name of Patient:______________________________02. Date of Birth:_________________03. Sex: M/F

04.Date of Consultation:___________________________05. Diagnosis:___________________________________

06.Planned Treatment:____________________________07. Recommendation:____________________________

08.Name of physician:____________________________09. Expected cost of treatment:_____________________

10.When was the Heart Problem diagnosed:________________________________________

11.Was the heart problem diagnosed during pregnancy? ______________________________

Doctors Signature:______________________________

Part-2 For the Parents of Patients.

01.Patients Father/Guardian Name:_____________________________________02. CNIC:__________________

03.Qualification:_________________________________04. Occupation:_________________________________

05.Mother Name:________________________________06. Qualification/Profession:_______________________

07.Details of family members:_______________________________________________________________________

08.Home/ Postal Address:__________________________________________________________________________

09.Phone No:___________________________________10. Mobile No:__________________________________

11.Email Address:________________________________12. Total monthly income of the family:______________

13.Do you own house or rented accommodation:______14. Source of Referral:____________________________

15.Do you have passport (Father / Mother): Yes/ No16. Can you help to arrange funds for CHHRI Yes/ No

17.Do you want to be volunteer for CHHRI: Yes/ No18. Are you eligible for Zakat: Yes/ No

19.You do not have any problem in case we contact you for marketing information?: Yes/ No

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as may be necessary in arriving any decision and also authorize PCHF to marketize kids pictures, video and parents interview on any platform.

Signature of Parents:_________________________

Part-3 For Management of Pakistan Childrens Heart Foundation.

Case: Deserving / Not Deserving Funds: ____________ Available / Not Available, Parents Share:________

Evaluation Officer: Approved by Chief Medical Advisor: Chief Executive Officer

Signature: _____________ Signature: _________________ Signature: ______________

Address: 9-B/1 Johar Town Lahore Phone: +92 322 2591460www.chhri.org.pk