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Grace Community Resource Network: COVID Requirement Form
C/o. New Grace English School, Sr. No. 46, Lane No. 2, Meethanagar, Kondhwa Khurd, Pune 411048
www.gracecrn.org
COVID Helpline Email:
covidhelp@gracecrn.org
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* Indicates required question
What is your COVID need?
*
Ambulance Service
Beds Without Oxygen for Isolation
Beds With Oxygen for Isolation
ICU Beds Without Ventilator
ICU Beds With Ventilator
Coordination for Hospitalization
Plasma Donation
Oxygen Arrangements at Home
Pickup and Drop Facility For Vaccination
Funeral Services
Other:
Required
Patient First Name
*
Your answer
Patient Last Name
*
Your answer
Patient Blood Group
Your answer
Patient Age Name
Your answer
Detail description about patients current health (Oxygen level, HRCT Score, Blood Pressure, Temperature)
Your answer
Detail description about patients existing aliments if any
Your answer
Your First Name
*
Your answer
Your Last Name
*
Your answer
Your Phone Number
*
Your answer
Your Alternate Phone Number
Your answer
Your Address
Your answer
Your Email Address
Your answer
Relation with the Patient
Father
Mother
Uncle
Aunty
Son
Daughter
Other:
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Notes
Your answer
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