Application for Medical Advance

APPLICATION FOR THE ADVANCE OF MEDICAL TREATMENT

|1) Name & Designation |: | |
|2) Office in Which working |: | |
|3)a) Basic Pay |: | |
|b)Dearness Pay | | |
|Total | | |
|4) Whether Permanent or Temporary? |: | |
|5) Name of the Patient and relationship |: | |
|with the Government Servant. | | |
|6) Nature of Illness |: | |
|7) Whether treatment is received as in-patient or outpatient? |: | |
|8) Name of the Hospital in which patient is treated and whether |: | |
|it is recognised one? | | |
|9) Whether Necessary certificate from the Medical Officer/ |: | |
|Specialist of the