Feedback Form - United Health And Welfare Trust

Feedback Form

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Patients Name

First

Last

Name of the disease

How many units of blood was needed ?

Aadhaar Number

First

Last

Requisition Slip / C.R / I.P / Registration Number

Name of the Hospital/Clinic

Hospital/Clinic Address

Hospital Address Line 2

Attendants Name

First

Last

Attendants Mobile Number

Attendants Whatsapp Number

Patients Address

Address Line 2

Town/City, District & State

First

Middle

Last

Confirm Email

What would you like to say about United Health & Welfare Trust's Team for providing Free of Cost blood ? We would really appreciate your Feedback !

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