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Admission Form
AFMEC Trust Covid Pre Hospital Primary Support service
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Email
*
Your email
Name
*
Your answer
Age
*
Your answer
Gender
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Female
Male
Other
Address
*
Your answer
Adhar Card No
*
Your answer
Contact no
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Your answer
Contact person name
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Your answer
Suffering From .... days
*
Your answer
Other Disease
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Your answer
Doctor's Name
*
Your answer
Doctor's contact no
*
Your answer
Antigen Test
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positive
negative
not done
RTPCR
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POSITIVE
NEGATIVE
NOT DONE
AWAITED
HRCT
*
Your answer
OXYGEN LEVEL WITH SUPPORT (SPO2) Oxygen level under 80 will not be admitted
*
Your answer
OXYGEN LEVEL WITHOUT SUPPORT (SPO2) Oxygen level under 80 will not be admitted
*
Your answer
Request for admission in AFMEC Trust Covid Help centre. I declare I am at my own risk , (I know that AFMEC Trust Covid Help is for primary Relief or Oxygen support and it’s Not a Hospital )
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Admission Date
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Hall Number
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Bed Number
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Afmec's Doctor Name
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Afmec Hospital Remark
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